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[ { "category": "Radiology", "chartdate": "2116-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841464, "text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval et placement\n Admitting Diagnosis: GI BLEED,HYPOTENSION,FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with hematemesis/GI bleed, melena now with\n increased rhonchi\n REASON FOR THIS EXAMINATION:\n eval et placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 y/o man with hematemesis and GI bleed. Now with increasing\n rhonchi. Evaluate endotracheal tube placement.\n\n FINDINGS: AP portable semi-upright film demonstrates the endotracheal tube\n with appropriate position. Its tip is 5 cm above the carina. A nasogastric\n tube is coiled within the stomach. There are low lung volumes and there is a\n linear opacity in the right hemithorax medially consistent with collapse of\n both the right middle and right lower lobes. There is peripheral cystic\n changes in the upper lobes bilaterally which may be due to a chronic\n infiltrative process. This is also present on a film from . There is\n a left retrocardiac opacity as well as linear opacity in the left lung base.\n\n There is an unusual appearance to the stomach in the upper abdomen, appears\n more dense than normal and both sides of the bowel wall are seen. Correlation\n is recommended with the patient's abdominal imaging.\n\n IMPRESSION:\n\n 1) Appropriately placed endotracheal tube.\n 2) Collapse of both the right middle and right lower lobes.\n 3) Consolidation/opacity in the left lung base; this is likely atelectasis\n however developing pneumonia can't be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841421, "text": " 8:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusion or infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with hematemesis/GI bleed, melena\n REASON FOR THIS EXAMINATION:\n assess for effusion or infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a 71-year-old man with hematemesis.\n\n COMPARISONS: .\n\n CHEST, AP SINGLE VIEW: There are low lung volumes. The cardiac, mediastinal,\n and hilar contours are unchanged. There is increased opacity in the left\n lower lobe, but this is unchanged when compared to the prior study. There is\n platelike atelectasis in the right lower lobe. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-09-21 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 841437, "text": " 4:12 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: failure, infiltrate\n Admitting Diagnosis: GI BLEED,HYPOTENSION,FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with hematemesis/GI bleed, melena now with\n increased rhonchi\n REASON FOR THIS EXAMINATION:\n failure, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n Comparison to previous study of one day earlier.\n\n CLINICAL HISTORY: Worsening rhonchi.\n\n Comparison made to earlier study of .\n\n The nasogastric tube is in place, terminating within the stomach, coiled\n within the structure. The cardiac and mediastinal contours are within normal\n limits in size for technique. A note is made of collapse involving the right\n middle and right lower lobes. There is also worsening patchy opacity in the\n left retrocardiac area. Peripheral interstitial lung disease is noted,\n particularly in the right upper lobe.\n\n IMPRESSION:\n\n 1. Right middle and lower lobe collapse.\n 2. Left retrocardiac opacity, which may relate to atelectasis, aspiration or\n pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2116-09-21 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 841434, "text": " 3:37 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: assess for abscess, diverticulitis, colitis, appendicitis\n Admitting Diagnosis: GI BLEED,HYPOTENSION,FEVER\n Field of view: 44 Contrast: VISAPAQUE Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, abdominal pain, hypotensive, coffee ground emesis\n REASON FOR THIS EXAMINATION:\n assess for abscess, diverticulitis, colitis, appendicitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe MON 4:44 AM\n ascities, stranding of the mesentery in the rlq. appendix, and TI are non-vis.\n Given pt history of hypotension occult bowel injury cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: 71 year old man with fever, abdominal pain and coffee ground emesis\n with a hypotensive episode to 80/60.\n\n COMPARISON: None.\n\n TECHNIQUE: Multiple axial images from the lung bases to pubic symphysis were\n obtained following the administration of 150 cc of Visipaque. Visipaque was\n used secondary to patient's elevated creatinine.\n\n CT ABDOMEN WITH IV CONTRAST: The lung bases demonstrate some dependent\n bibasilar atelectasis. There are coronary artery calcifications seen in the\n few images of the heart.\n\n The patient is status post cholecystectomy. In the liver, there are numerous\n low attenuation lesions. The largest is near the dome of the liver seen on\n series 2, image 12. There are smaller foci, two in the left lobe, and two\n additional low attenuation lesions in the right lobe of the liver.\n There is periportal adenopathy. The spleen and pancreas are unremarkable. The\n kidneys are unremarkable with the exception of a simple cyst in the lower pole\n of the left kidney measuring up to 2.9 cm in diameter.\n\n There is a moderate amount of ascites surrounding the liver and extending in\n the right paracolic gutter. Some fluid extends around the spleen as well.\n There is stranding of the mesentery in the right lower quadrant with collapsed\n cecal and abdominal ileum loops with the appendix nonvisualized. There are\n numerous foci of free air in the abdomen and in the right lower quadrant. Thre\n is fecalization of the terminal ileum.\n\n The celiac, SMA, , and renal arteries are patent. The portal veins and\n hepatic veins are patent. In the left upper quadrant of the abdomen there are\n numerous scattered enlarged mesenteric lymph nodes. There are fluid filled\n nondilated distal small bowel loops.\n\n CT PELVIS WITH IV CONTRAST: There is a small amount of free fluid tracking\n into the pelvis. There is a Foley catheter in the bladder with air in the\n (Over)\n\n 3:37 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: assess for abscess, diverticulitis, colitis, appendicitis\n Admitting Diagnosis: GI BLEED,HYPOTENSION,FEVER\n Field of view: 44 Contrast: VISAPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n bladder presumably from Foley catheter insertion. The rectum is unremarkable.\n There is diverticulosis of the sigmoid colon withut diverticulitis.\n\n REFORMATTED IMAGES: Reformatted images in the coronal and sagittal planes\n confirm the presence of ascites as described above.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions.\n\n These findings were discussed with the surgical resident on call as well as\n with the emergency room resident taking care of this patient. Revised finding\n of free air discussed with Dr at 8 AM .\n\n\n IMPRESSION:\n 1) Stranding in right quadrant with surrounding ascites and adjacent foci of\n free air makes distal small bowel perforation most likely. This could be\n secondary to hypotensive episodes. However, additional history from the\n surgical team was obtained, the patient has had remote gastric tumor, the\n liver lesions and mesenteric and portal nodes could represent metatstic\n disease wth bowel perforation from tumor involvement.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-09-21 00:00:00.000", "description": "Report", "row_id": 1272381, "text": "PT @ 1900. MOEPHINE GIVEN AT THAT TIME. FAMILY AT BEDSIDE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-09-22 00:00:00.000", "description": "Report", "row_id": 1272382, "text": "neuro: pt moves all extremities on bed to command,lethergic but opens eyes when name is called. nods appropriately to questions. no verbal responses. pupils equal.pinpoint.on morphine drip for pain management\n\ncv: sbp 104-89/ hr 133-120 st occasional pvc.\n\ngi: abd distended,soft. no bowel sounds. pt nods yes to apin when abdomen is touched.\n\ngu: foley draining amber yellow urine in 25-30cc/hr\n\npain management: pt started on morphine drip at 1 mg/hr at . when turning at 220 pt grimaced and when questioned about pain he nodded yes so morphine increased to 2 mg/hr. about 0100 pt lying with eyes opened and nodded yes when questioned about pain in his abdomen so drip increased to 3 mg/hr. pt is comfortable at present dose of 3 mg/hr he nods no when he is questioned about his pain.\n\nhis temp spiked to 102.5 po. he received tylenol 650 mg pr times one. his temp is down to 96.9 po.\n\nIV access; patient has r radial aline, r femoral cordis with a tri[ple lumen through it. one peripheral iv has been started in his left posterior forearm.\n\nsister and nieces were here visiting at bedside in the evening.\n" } ]

[ { "category": "Radiology", "chartdate": "2151-08-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024206, "text": " 11:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: condition of lungs\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n post op\n REASON FOR THIS EXAMINATION:\n condition of lungs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old, post lumbar spine surgery. Evaluate condition of\n lungs.\n\n No prior examinations.\n\n SINGLE AP SUPINE BEDSIDE CHEST RADIOGRAPH: Lung volumes are low. Bibasilar\n atelectasis and effusions are consistent with the patient's post-operative\n status. There is no parenchymal opacity or evidence of edema. Widening of\n the mediastinum is likely due to the supine technique and mediastinal fat. If\n there is concern for mediastinal hematoma, a CT of the chest would be\n necessary.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-12 00:00:00.000", "description": "LUMBAR SP,SINGLE FILM", "row_id": 1024165, "text": " 3:28 PM\n LUMBAR SP,SINGLE FILM Clip # \n Reason: SURGERY\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE LATERAL VIEW OF THE LUMBAR SPINE DATED \n\n HISTORY: Surgery.\n\n TECHNIQUE: Limited series of three intraoperative lateral views (the latter\n two of which are labeled \"#2\" and \"#3 in OR\") demonstrate placement of\n surgical instruments and posterior fusion device at the L4-5 level, where\n there is a grade I anterolisthesis. Please refer to operative note for\n further details.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-23 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1025796, "text": " 10:55 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE EVALUATE FOR DVT\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with known PE\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb MON 12:23 PM\n Negative for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND .\n\n INDICATION: 66-year-old man with known pulmonary embolism.\n\n FINDINGS: There is normal compressibility, waveform, color Doppler signal,\n and augmentation of the lower extremity veins from the level of the common\n femoral through the tibial veins.\n\n IMPRESSION: Negative for DVT bilaterally.\n\n\n\n\n Clip #: \n DOS: \n PFI: Negative for DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-12 00:00:00.000", "description": "L HUMERUS (AP & LAT) LEFT", "row_id": 1024124, "text": " 12:38 PM\n HUMERUS (AP & LAT) LEFT Clip # \n Reason: 66 year old man with l triceps pain, please r/o fx\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with l triceps pain, please r/o fx\n REASON FOR THIS EXAMINATION:\n 66 year old man with l triceps pain, please r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left humerus two views .\n\n HISTORY: 66-year-old male with left triceps pain. Evaluate for fracture.\n\n FINDINGS: No previous studies available for direct comparison.\n\n There are no signs of acute fractures or dislocations. There are mild\n degenerative changes seen at the AC joint. No abnormal soft tissue\n calcifications are seen.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-26 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 1026424, "text": " 11:09 AM\n L-SPINE (AP & LAT) Clip # \n Reason: Assess hardware alignment s/p PLIF\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p PLIF on and PE\n REASON FOR THIS EXAMINATION:\n Assess hardware alignment s/p PLIF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lumbar fusion.\n\n Four radiographs of the lumbar spine demonstrate the patient to be status post\n L4-L5 posterior metallic spinal fusion and L4 laminectomy. When compared to\n , the fusion is new. There is partial interval reduction of the\n L4-L5 anterolisthesis seen on . 4-5 mm of anterolisthesis are\n present at L4-L5. A radiolucent intervertebral body spacer is seen at L4-L5.\n Hip and sacroiliac joints are unremarkable. Symphysis pubis is normal. The\n AP view suggests the L4-L5 intervertebral body spacer device is to the right\n of midline. Correlation with surgical history is requested.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-13 00:00:00.000", "description": "FLUORO GUID FOR SPINE DIAG/THERAPEUTIC INJ", "row_id": 1024356, "text": " 4:52 PM\n LUMBAR PUNCTURE Clip # \n Reason: 66 year old man with dural leak, needs lumbar drain please\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n Contrast: NON IONIC Amt: 5\n ********************************* CPT Codes ********************************\n * SPINAL PUNCTURE/DRAINAGE FLUORO GUID FOR SPINE DIAG/THE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with dural leak, needs lumbar drain please\n REASON FOR THIS EXAMINATION:\n 66 year old man with dural leak, needs lumbar drain please\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR DRAIN PLACEMENT\n\n HISTORY: The patient is a 56-year-old-male status post lumbar laminectomy with\n a dural leak.\n\n Informed consent was obtained from NOK via telephone, after explaining the\n risks, indications, and alternative management.\n\n The patient was brought to the fluoroscopic suite and placed on the\n fluoroscopic table in the prone position. Access to the lumbar subarachnoid\n space was obtained using a 19 gauge needle under local anesthesia using\n 1% lidocaine with aseptic precautions. The needle was removed, the guidewire\n was removed after placement of a Hermetic lumbar closed tip catheter.\n Serosanguineous CSF flowed through the catheter and 5 cc of Isovue- M-300 was\n injected into the subarachnoid space to confirm placement of the catheter at\n the L3 level. The lumbar closed tip catheter was inserted up to 50 cm. A\n lumbar closed range system was attached and the catheter was sutured in place\n and a dressing applied. The patient tolerated the procedure well without any\n immediate complications and sent to the floor with post procedure orders.\n\n Access was obtained to the level of L3.\n\n Moderate sedation was provided by administering continuous doses of propofol\n drip as well as 1 mg of Versed throughout the 35 minute intraservice time\n during which the patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Successful fluoro guided lumbar drain placement. Dr. ,\n the attending neurointerventionalist, was present supervising throughout the\n entire procedure.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-23 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1025797, "text": ", W. NSURG SICU-A 10:55 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE EVALUATE FOR DVT\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with known PE\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n PFI REPORT\n Negative for DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-14 00:00:00.000", "description": "O L-SPINE (AP & LAT) IN O.R.", "row_id": 1024461, "text": " 3:10 PM\n L-SPINE (AP & LAT) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: SPINAL DRAIN PLACEMENT\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Spinal drain placement.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Single spot view obtained. Fluoro time not recorded on\n the electronic requisition. View demonstrates pedicle screws spanning two\n levels in the lumbar spine. Assessment of fine bony detail is limited by RF\n technique. Correlation with real-time findings is recommended for full\n assessment.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-22 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1025702, "text": " 5:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for pulmonary embolus\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with sudden onset chest pain and increased respiratory effort\n with ambulation\n REASON FOR THIS EXAMINATION:\n please evaluate for pulmonary embolus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CLxc SUN 10:32 PM\n PFI: Large bilateral pulmonary emboli. These findings were discussed with\n , neurosurgery nurse practitioner, at approximately 5:50 p.m.\n on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year old man with sudden-onset chest pain and increased\n respiratory effort with ambulation, please evaluate for pulmonary embolus.\n\n TECHNIQUE: 5-mm contiguous axial images from the thoracic inlet through the\n adrenal glands without IV contrast were obtained. 2.5-mm contiguous axial\n images from the thoracic inlet through the adrenal glands with IV contrast\n were obtained. Coronal and sagittal reconstructions at 5-mm collimation were\n included in this study. No prior studies are listed for comparison.\n\n FINDINGS: There are large bilateral pulmonary emboli. Thrombus is seen in\n the left main pulmonary artery extending into the left upper lobe, lingular\n and left lower lobe branches. Thrombus is also seen at the bifurcation of the\n right pulmonary artery which extends into and fills all of the branches of the\n right upper lobe pulmonary arteries. There is non-occlusive thrombus in the\n right middle lobe. Thrombus also involves all of the segmental branches of\n the right lower lobe. The right atrium and right ventricle appear enlarged.\n Although CT cannot definitively diagnose right heart strain, these findings\n are supportive of the patient's known right heart strain on EKG.\n\n Ground-glass opacities are noted in the right upper lobe. No evidence of\n pericardial or pleural effusion. Central airways are patent. Incidental note\n is made of a ductus diverticulum which contains calcified mural plaque. The\n thoracic aorta is otherwise unremarkable. No evidence of axillary,\n mediastinal or hilar lymphadenopathy.\n\n The visualized portion of the liver demonstrates a hypoattenuating lesion\n adjacent to the gallbladder fossa which likely represents focal fat. The\n gallbladder is unremarkable. Visualized portions of the pancreas, spleen,\n adrenal glands and kidneys are unremarkable. Incidental note is made of two\n splenules in the left upper quadrant.\n\n BONE WINDOWS: Multilevel flowing syndesmophytes are seen throughout the\n thoracic spine, consistent with diffuse idiopathic skeletal hyperostosis. No\n suspicious osteolytic or osteoblastic lesions are identified.\n\n (Over)\n\n 5:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for pulmonary embolus\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Massive bilateral pulmonary emboli.\n\n 2. Right atrium and right ventricle appear dilated. Although CT cannot\n definitively diagnose right heart strain, these findings are supportive of the\n patient's known right heart strain on EKG.\n\n 3. Non-specific ground-glass opacities in the right upper and left lower\n lobes are likely related to pulmonary emboli.\n\n 4. Diffuse idiopathic skeletal hyperostosis of the thoracic spine.\n\n Critical findings were discussed with nurse practitioner, ,\n at approximately 5:50 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-22 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1025703, "text": ", W. NSURG FA11 5:13 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for pulmonary embolus\n Admitting Diagnosis: LUMBAR STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with sudden onset chest pain and increased respiratory effort\n with ambulation\n REASON FOR THIS EXAMINATION:\n please evaluate for pulmonary embolus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Large bilateral pulmonary emboli. These findings were discussed with\n , neurosurgery nurse practitioner, at approximately 5:50 p.m.\n on .\n\n" }, { "category": "Echo", "chartdate": "2151-08-25 00:00:00.000", "description": "Report", "row_id": 85148, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary embolus. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 325\nBSA (m2): 2.62 m2\nBP (mm Hg): 121/75\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 10:39\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with 35-50%\ndecrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Moderate symmetric LVH. Top normal/borderline dilated LV\ncavity size. Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT\ngradient. No VSD.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Markedly dilated aortic sinus. Moderately dilated ascending aorta.\nMildly dilated aortic arch.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is 0-10mmHg. There is moderate\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\ntop normal/borderline dilated. Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Overall left ventricular\nsystolic function is normal (LVEF>55%). There is no ventricular septal defect.\nThe right ventricular cavity is mildly dilated with mild global free wall\nhypokinesis. The aortic root is markedly dilated at the sinus level. The\nascending aorta is moderately dilated. The aortic arch is mildly dilated.\nThere is mild to moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: RV strain.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-08-23 00:00:00.000", "description": "Report", "row_id": 1669087, "text": "SICU Nursing Note: See flowsheet for details\nPt remains on heparin gtt, rate increased after 0800 PTT subtherapeutic. Denies pain, SOB. Fio2 weaned to 4L N/C. LS clear, diminished at bases. Tolerating regular diet. Per neurosurgery, we are to keep a DSD on surgical incision site, dressing to be changed by neurosurgery on rounds - if there is drainage noted we are to inform neurosurgery. LENI's completed - prelim. negative; EKG obtained. wife called this AM - informed as to pt. status and questions answered in a detailed manner. In addition, patient relations contact and touched base with wife this morning in regard to her request for a patient advocate appointed. Social work also contact and will follow up.\n\nPLAN: stepdown when bed opens, continue hep gtt, PT resume tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2151-08-23 00:00:00.000", "description": "Report", "row_id": 1669088, "text": "SICU Nursing Addendum Note\nPer Neurosurgery/, heparin gtt protocol D/C'ed and we are to consult neurosurgery for orders for each PTT result for an order. Currently, patient is on 1400 units/hour per neurosurgery and did receive a 2900 unit bolus per protocol before it was discontinued. PTT check due at 2100.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-24 00:00:00.000", "description": "Report", "row_id": 1669089, "text": "Neuro: Alert and oriented x 3 Denies pain. Mae to command.\n\nCv/resp Nsr rate in 70's. Bp stable. Lungs clear o2 3lnp good o2 sats.\n\nGi/Gu voiding large amts clear yellow urine. no bm this shift. Tolerating fluids good appetite.\n\nRemains on Heparin gtt. increased to 1500units per hour per neurosurgery. This am's PTT still pending.\n\nPlan SDU when bed avail. Heparin to therapeutic ptt 60-80. OOB today with PT. Page Neurosurgery with all PTT results for heparin change orders. Next PTT check 11am today.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-24 00:00:00.000", "description": "Report", "row_id": 1669090, "text": "Am PTT reported to neurosurgery. Heparin gtt incresed to 1700u/hr and ptt to be rechecked in 6 hours (1300).\n" }, { "category": "Nursing/other", "chartdate": "2151-08-14 00:00:00.000", "description": "Report", "row_id": 1669070, "text": "UPDATE\nO: See carevue flowsheet for specifics.\nNeuro:sedated on ppfl and fent. Sedation lifted q4h for neuro exam. Pt opens eyes to voice, mae spont and to command(inconsistently), pserl at 2mm brisk.Lumbar drain open w scant amts of bld tinge drng. Lumbar drain irrig by Dr and w min incr in drng.Lumbar dsg w mod to lg amt of ssang drng(Dr & aware).Occas ativan for restlessness when arousable.Follow CIWA scale, no signs of acute withdrawal at this time.\n\nCV: Skin and dry.sr no ectopy. Sbp stable 120-150's. Distal pulses faint palp, cool to touch.\n\nResp: cpap w w stv 550-650. Bbs clear upper lobes, very diminish bibas. O2 sat stable on 50% fio2. Lavage and suct for sm amt of thick pale yellow secretions. VAP protocol maintained.\n\nGi: abd soft, no active bowel snds audible. Ogt placed and drained 150cc initially of thick dk green bilious.PPI for gi prophylax.Glucoses wnl.\n\nGu: foley to gd q cl yellow urine.\n\nHeme/Id: am labs pending. Tmax 99.8, received last dose kefzol this pm.\n\nSkin: Pink areas anterior chest w sm blisters just below nipple line, bilat pink areas on sacro iliac region(no brkdwn)? d/t contact irritation while proned in IR earlier today.lumbar dsg w lg amt ss drng.\n\nA/P: Plan per Dr pt remain sedate, supine overnight, continue leave lumbar drain open to gravity,clamp prn dnrg > 15cc/hr.Check am lab results & rx lytes per slide scale. Pulm toilet,Vap protocol.To be reeval in am by Dr team for further instruct re: weaning, reposition, poc.Cont to monitor CIWA scale.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-14 00:00:00.000", "description": "Report", "row_id": 1669071, "text": "resp care note\npt remains on psv . bs clr. sx small amount of yellow. last abg 7.38/47/89. plan to remain intubated for ir.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-14 00:00:00.000", "description": "Report", "row_id": 1669072, "text": "condition update\nplease see carevue for specifics.\n\nPt intubated and sedated on 40 mcqs/ hr ppf gtt. PPF gtt turned off this am for wake up. Pt opening his eyes spontaneously. Able to mae, and following commands consistently. PERRL. No ativan given per CIWA scale score this shift. Tmax 100. SR. No ectopy noted. HR 80's. BP 106-141/50-56. Fentanyl gtt infusing currently at 50 mcqs/ hr. LS are dimininshed at b/l bases. Pt sxn'd for sml amts of thick, yellow secretions. Pt on cpap Fi02 50% Remains NPO. D5 1/2 NS infusing at 50cc/ hr. Foley patent and draining adequate amts of urine. OGT to sxn w/ moderate amts of bilious drainage. Pt went to the OR this aternoon to replace his leaking lumbar drain. Old drain saturating the dressing w/ lg amts of bld tinged CSF. New lumbar drain placed in the OR now w/ clear csf drainage. Drain to remain clamped and to drain 15cc/ hr per nsurg. Will notify nsurg if drainage 5cc/ or < hourly. DSD w/ tegaderm to cover new drain. Pt on hourly neuro checks post op. Pt also being weaned post op to prepare for possible extubation.\n\nPlan: continue w/ current plan of care per sicu/ nsurg teams. Continue to closely monitor neuro exam hourly and drain lumbar drain 15cc/ hourly. PPF gtt for sedation. Fentanyl gtt for pain mgmt. Ativan per CIWA scale. Wean vent settings as tolerated. PRN electrolyte repletions.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-23 00:00:00.000", "description": "Report", "row_id": 1669086, "text": "Update- readmit to SICU\nO: Pt readmitted to sicu after trigger on floor for acute sob, hypotension,desat,tachycardia & confirmed r/i PE by CT scan.Adm to icu aaoriented on 10 lpm ventimask w sats 96-99%, 110-115 on adm. bbs clear upper lobes diminish bibasilarly. Heparin gtt at 1500u/hr after 2700 u bolus on floor.Pt denied cp or sob at this time. Additional periph iv access achieved and coags checked q2h until ptt stabilized. Heparin gtt currently at 900u/hr.(off x 1hr w ppt > 150 shortly after adm). to sr 115-80's no ectopy. sbp 100-120's, O2 sats > 95% on ofm 96 po Ciwa scale followed, pt skin cool moist, diaphoretic no signs of withdrawal.Pt c/o neck pain this am and med for same w oxycodone 10mg w gd response. Continues to receive oxycontin as well. lumbar incision w staples intact, incision pink no drng noted, slt edema at site. Wbc 15 this am.Vdg qs cl yellow urine. Pt tol po's in sm amts overnight. Abd soft obese, + bowel snds.Compression sleeves on bilat per orders.\n\nA/P: s/p PE- plan anticoag w heparin gtt titrated per protocol q6h ptt. Observe for s/s of hypoxia,notify ho for any s/s acute hypoxia,maintain strict bedrest. Med for pain as needed. ? IR for ivc filter.Cont to monitor ciwa scale, med approp.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-14 00:00:00.000", "description": "Report", "row_id": 1669073, "text": "BS CTAB. Small amount yellow secretions. To OR for replacement of leaky lumbar drain. Upon return, weaned to CPAP 5/5 with RSBI 29. At moment pt appears to groggy to extubate with rr - 10. Keep on PSV while comfortable. RN concerned about sat of 94. Consider increasing PEEP if sat continues to drop. Back on AC if necessary and hopefully, wean to extubate in AM.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-15 00:00:00.000", "description": "Report", "row_id": 1669074, "text": "condition updated\ns/p Laminectomy/fusion\nFor detail info please refer to carevue flowsheet;\nPt awake and follows commands off propofol. c/o back pain fentanyl increased and PPF weaned to off. required vent support though the night for poor O2/ventilation. more awake and aware as night progressed. increased tongue action with ngt/ett. kept PPF off and weaned vent to . pt calms with instruction and now ready to extubate.\nlumbar drain draining 15cc/hr then clamped as per neuro orders. MAE stiffly. LABS wnl cefazolin restarted for drain\nPOC:\nextubate, sleep apnea risk ?evaluation\n? increased activity\npain management\n" }, { "category": "Nursing/other", "chartdate": "2151-08-15 00:00:00.000", "description": "Report", "row_id": 1669075, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on minimal vemt settings. RSBI completed on PS 5=17. Plan to extubate this AM.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2151-08-15 00:00:00.000", "description": "Report", "row_id": 1669076, "text": "condition update\nplease see carevue for specifics.\n\npt alert and oriented. Fentanyl gtt infusing at 30 mcqs/ hr. Pt hallucinating. Nsurg team notified. fentanyl gtt stopped. Pt c/o mild back pain. No further pain meds given for now. Pt able to mae. PERRL. Nsurg team changed back and lumbar drain dressings this am. Lumbar drain w/ clear csf and being drained Q hour. Tmax 99.1 SR. No ectopy noted. HR 80's-90's. BP 141-160/60-68. LS diminished at the bases b/l. Reg diet ordered. IVF Kvo'd. Foley patent and draining adequate amts of urine. Pt w/ 2 sml watery stools.\n\nPlan: continue w/ current plan of care per sicu/ nsurg teams. continue to closely monitor neuro exam Q 2 hours. Drain lumbar drain hourly for 20cc/ hr. Hold for HA. Notify Nsurg for < 10cc/ hour drainage from lumbar drain. Pt to remain on bedrest while lumbar drain in place. Encourage Po's. Dilauded for pain mgmt. Ativan per CIWA. RISS for bs coverage. Bipap tonight for sleep apnea.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-16 00:00:00.000", "description": "Report", "row_id": 1669077, "text": "RESPIRATORY CARE NOTE\n\nPatient observed for clinical signs/symptoms of OSA. No periods of apnea observed on 3 lpm nasal cannula. No periods of apnea or desaturation post extubation on or during the night of . Will re-evaluate if status changes.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2151-08-16 00:00:00.000", "description": "Report", "row_id": 1669078, "text": "condition updated\nS/P Laminectomy w/fusion\nFor complete detail info please refer to carevue flowsheet\nPt is neuro stable lumbar drain being drained 20cc/hr otherwise clamped. CSF is clear. LEFT ARM/SHOULDER is weaker due to past muscle injury.\nBP remains elevated despite po/IV hydralazine, med for pain w/dilaudid x2 and given 1mg ativan for anticipated withdrawal.\nPOC:\nHOB < 30 per neuro, lumbar drain 20cchr\nHTN control\n" }, { "category": "Nursing/other", "chartdate": "2151-08-13 00:00:00.000", "description": "Report", "row_id": 1669066, "text": "Please See Carevue for Specifics.\n\nPt arrived from OR to SICUa at MN after having a laminectomy and fusion of L4-L5 due to a herniated disc. No past medical history found in chart, although pt is a known to be a heavy EtOH.\n\nWhen propofol stopped, pt opens eyes and follows commands. NSR, no ectopy. SBP 100-120's. Lungs are clear, abd is obese with hypoactive BSX4. Foley with c/y/u. Skin is intact.\n\nPOC: Pt is to remain still and horizontal for 24 hours per surgical team. Continue to monitor mental status, pain, and CIWA. Discuss activity level with team. Continue to offer emotional support to pt and pt family throughout hospital stay.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-13 00:00:00.000", "description": "Report", "row_id": 1669067, "text": "REsp Care: Pt adm from OR intubated #7.5 oett secured @ 22 @ lip, placed on ventilatory support with a/c maintaining mild resp acidosis with acceptable oxygenation; bs clear to coarse, sxn no secretions, apneic for rsbi attempt, will wean when awake.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-13 00:00:00.000", "description": "Report", "row_id": 1669068, "text": "pt weaned to PSV this shift, plan was to extubate but pt required procedure in IR and therefore will remain intubated, sx'd for minimal secretions. plan to revaluate for wean in AM.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-13 00:00:00.000", "description": "Report", "row_id": 1669069, "text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt wakes off propofol gtt and follows commands, MAE lift and fall. Pupils equal and reactive. However pt becomes agitated and restless off propofol and when lightened. Shakes head yes to pain and fent gtt started with good effect. Propfol decreased with addition of fent gtt. Ativan x 1 for ciwa 13 while waking for extubation. Per neurosurg team and sicu team ok to sit pt up 30 degrees for extubation. Pt sat up 1200 and then at 1500 pt was turned and large amount of serosang/?csf on pad and dressing. SICU and neurosurg notified and in the evaluate pt. Extubation held off at this time and pt back to flat in bed. TO IR for lumbar drain placement continuing on fent/propfol. Pt proned for procedure. Pt has just returned to the unit and drain is to remain clamped. Neurosurg will be up to give all other orders. Please refer to carevue for all other details. Plan: awaiting orders from neurosurg post IR lumbar drain placement.\n\n" }, { "category": "Nursing/other", "chartdate": "2151-08-18 00:00:00.000", "description": "Report", "row_id": 1669082, "text": "nursing note\nSee carevue for specifics\n\nNeuro: A&Ox3 HOB remains flat, MAE. Perrla @2. C/O pain in neck and back. Percocet po started with good effect. Lumbar drain draining 25ml/hr clear csf. Dsg's D&I.\n\nCV: Hr sr 70's-80 no ectopy seen. At 0230 pt hr down to 40's-50's. Resident notified. EKG done. Pt denies cp,sob. SBP 140-180's. Received hydrilazine x1. Bringing SBP down to 140's.\n\nResp: Ls clear with dim bases. 02 sat 97-99% on 4lnc. Occ down to 89-92% when sleeping.? OSA.\n\nGI/GU: Abd snt +bs. +flatus no Bm. FC draining cyu in adequate amts.\n\nPOC:\nComtinue to monitor neuro. Drain lumbar drain 25ml/hr. Call neuro if <10ml drains.\nMonitor hr\nKeep HOB flat\nMedicate for pain as needed.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-08-18 00:00:00.000", "description": "Report", "row_id": 1669083, "text": "Addendum\nSBP for most of shift elevated. Discussed with SICU resident because goal of SBP 140-160 not acheived. PO hydralazine with little effect. SICU resident accepting SBP<180.\nPt reporting constant discomfort. Started on PO percocet with IV dilaudid for breakthrough. Pt sleeping in naps waking up and ringing for pain medicine and falling back asleep. Pt a little foggy with events and time. Not recalling taking pills for pain or having ekg done. NSURG aware. This am pt complaining of h/a nsurg at bedside at this time and no new orders.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-18 00:00:00.000", "description": "Report", "row_id": 1669084, "text": "Nursing note (0700-1900) 16:30.\n\nNeuro.\nUnchanged neuro exam.\nComplaining of severe headaches when drain opened this am, followed by bradycardia to 40BPM, pt cool and clammy, MD's informed, monitored closely, improved gradually when drain clamped. Drain now only open until pt develops headache. No further episodes of bradycardia this shift.\nMedicated with Oxycontin with good effect.\n\nResp.\nLs clear, dim to bases, remains on 3l NC.\n\nCVS.\nHR now 70-80's NSR with no ectopy, less hypertensive, to start on clonidine for hypertension.\n\nGI/GU.\nTolerating small amounts of diet today, continues with liquid stool x2 today, given Loperamide x2.\nFoley patent for clear yellow urine in adequate amounts.\n\nSkin.\nPressure areas intact, pt able to turn in bed, remains on strict flat bedrest.\n\nSocial.\nWife at bedside most of day, updated by the team.\n\nPlan.\nContinue current POC.\nDrain Lumbar as able, but call neuro in less than 10cc.\n?? call out to floor in am.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-19 00:00:00.000", "description": "Report", "row_id": 1669085, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Hemodynamically stable overnight. Afebrile. SBP 100-130. HR 50-60 for most of night. At one point while draining CSF accidentally drained 30cc for the hour and pt complained of sore neck/HA and HR briefly to 40's. Otherwise pt tolerated draining 20cc CSF hourly without any discomfort. Pt also reported good pain control on oxycontin and only required prn oxycodone X1 when excess CSF drained.\n Overnight pt a/ox3 and MAE but occassionally is confused to events. This morning pt reporting conversations that did not take place overnight. Oriented to why he is in the hospital but thinks there was a \"drug bust\" that took place here and that the staff are cops.\n This am phlebotomy called to draw blood d/t RN's unable to obtain adequate amts of blood.\n Taking adequate amt of PO's. No stool overnight.\n Wife called and updated by RN\nPLAN:\n Transfer to floor today\n Cont to drain 20cc CSF hourly\n Oxycontin \n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2151-08-16 00:00:00.000", "description": "Report", "row_id": 1669079, "text": "condition update\nplease see carevue for specifics.\n\nPt alert and oriented x 3. Able to MAE. PERRL. Nsurg in this am and updated pt and his wife re: condition, plan of care. Back dressings both saturated w/ sero sang fluid. Dressings changed by nsurg team this am and also in the late afternoon d/t drainage. Lumbar drain to drain 25cc Q hour. Will notify Nsurg for < 10cc hourly drainage. Pt is allowed to lay flat only no reverse Md. . Neuro exam also changed to Q 4. No ativan given per CIWA protocol. Tmax 99.1 SR. HR 70's-80's BP 138-168/64-79. Low dose po lopressor started this am. Pt c/o moderate back pain. Pt currently receiving .5mg IV dilauded Q2 hours w/ + effect. LS diminished at B/L bases. 02 sats 93-97% on 3L 02 via n/c. Pt on a regular diet. He has not had much of an appetite only eating about 10% of meals. Dietician notified. Pt able to drink several cups of water. IVF remains HL'd. Foley patent and draining adequate amts of urine. Pt continues to have frequent watery stools. Cdiff spec sent. Loperimide started. BS 147, 116. No insulin coverge given.\n\nPlan: Continue w/ current plan of care per sicu/ nsurg teams. Continue to closely monitor neuro status Q4 hours. Pt to remain flat in bed. Draining 25cc csf from the lumbar drain hourly. Will notify nsurg for < 10cc/ hr. Pulmonary toilet. Dilauded for pain mgmt. Encourage po's. F/U on cdiff spec sent. loperimide for diarrhea. Ativan per CIWA protocol.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-17 00:00:00.000", "description": "Report", "row_id": 1669080, "text": "condition updated\ns/p laminectomy/fusion\nfor complete detail info please refer to carevue flowsheet\nPts neuro status unchanged. c/o moderate pain at change of shift and stated \"I can't take this pain anymore\" discussed with team to change to PCA pump. in wait for pump given(.5mg) dilaudid with 1mg ativan which kept pt pain free and comfortable x5hrs. PCA held and repeated same regime at 1am when pt at this point only c/o mild pain and again had + effects in pain reduction. @ 5am had episode of increased pain ()after draining lumbar drain. inadvertantly drained 40ml instead of 25ml due to distraction. given .5 mg and had relief.\nBP still 150-165 range lopressor and hydralazine given.\nThis am felt well enough eat toast.\nPOC:\nkeep flat\nlumber drain 25ml/hr\npain management ? starting PCA vs dilaudid/ativan combo\n" }, { "category": "Nursing/other", "chartdate": "2151-08-17 00:00:00.000", "description": "Report", "row_id": 1669081, "text": "Nursing note (0700-1900) 16:40.\n\nSee careview for specific details.\n\nNeuro.\nStatus unchanged, pian managed with Dilauded 0.5mg Q2hrs with good effect, was given 1mg Ativan this am with no real effect, on CIWA scale for potential withdrawl.\nPt requires 25cc of CSF draining from Lumbar drain Q1hr. Draining clear straw CSF.\n\nResp.\nSpO2 90-96% on RA, LS clear to UL's, dim to bases.\n\nCVS.\nLess hypertensive this shift, HR 70's NSR.\n\nGI/GU.\nPt tolerating PO diet well, passed small amount of liquid stool this pm.\nFoley patent for good volumes of clear yellow urine.\n\nSkin.\nAll pressure areas intact, pt has to remain flat in bed, can roll side to side briefly.\n\nSocial.\nWife at bedside most of day, updated by team.\n\nPlan.\n? tx to floor on Thursday.\nKeep flat in bed.\nDrain 25cc/hr from Lumbar drain.\nEncourage PO diet.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-24 00:00:00.000", "description": "Report", "row_id": 1669091, "text": "Nursing note 7a-7p\nShift uneventful. Up w/ PT to chair-tol well. Heparin gtt finally therapeutic. PTT @ 1900 pending. Started on coumadin today\n\n\nNeuro-intact, except for bilat thigh numbness and Rt great toe and right dp decreased sensation.\n\nCV-SR, no ectopy. palp. pulses.\n\nPulm-no distress on 3LNC. lungs clear w/ occasional wheeze.\n\nGI-benign. Tolerating House diet well.\n\nGU-voids per urinal.\n\nInteg-Lumbar inc/staples intact, well approximated. No drng. DSD changed.\n\nIV-#18 Rt hand heparin gtt @ 1900 units/hr\n NS @ KVO\n #20 SL LFA\n\nEndocrine-FSBS Q 6 hrs. SSI coverage as rx'd\n\nSoc-wife visiting.\n\n PTTs. to SDU tomorrow (?). PT/OT.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-08-25 00:00:00.000", "description": "Report", "row_id": 1669092, "text": "SICU Nursing Note: See flowsheet for details\nPt afebrile; SBP 110-138/70s, sinus rhythm 70s-80s no ectopy noted. Mild bilateral LE edema, + DP/PT pulses bilaterally; sensation intact. Denies pain except for mild headache at start of shift resolved with scheduled pain med. DSD intact staples; 1 suture where old drain site intact. Skin intact. Remains on 3L NC; heparin gtt within therapeutic range X3; level now re-checked once per day. One large BM guiac neg.\n\nPLAN: Heparin gtt, transition to coumadin, of which first dose administered yesterday; continue PT; staples due to be removed 10-14 days post-up - follow up with neurosurgery; transfer to stepdown or floor.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-25 00:00:00.000", "description": "Report", "row_id": 1669093, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS, PT TRANSFER TO 11= TRANSFER NOTE WRITTEN.\nNEURO: ALERT, ORIENTED X3, DENIES PAIN, BACK DRESSING INTACT\nCV: AFEBRILE. .\nRESP: BS CLEAR, NC AT 3 LITERS WITH SATS >96%\nGI: ABD SOFT, + FLATUS, APPETITE GOOD\nGU: VOIDING QS\nENDO: BS WNL\nACTIVITY: OOB TO CHAIR= DID WELL.\n" }, { "category": "ECG", "chartdate": "2151-08-23 00:00:00.000", "description": "Report", "row_id": 214826, "text": "Sinus rhythm\nExtensive T wave changes may be due to myocardial ischemia\nSince previous tracing of , heart rate slower, right bundle branch block\nresolved, ST segment depression in lateral leads, ST segment elevation in\ninferior leads. Inferior/anterior T wave inversion are new\n\n" }, { "category": "ECG", "chartdate": "2151-08-22 00:00:00.000", "description": "Report", "row_id": 214827, "text": "Sinus tachycardia. Right bundle-branch block. Slight ST segment elevation in\nlead III and to a lesser degree in lead aVF. ST segment depressions in\nleads I, aVL and V4-V6 raise consideration of myocardial ischemia. Clinical\ncorrelation and repeat tracing are suggested. Compared to the previous tracing\nof sinus tachycardia, right bundle-branch block and aforementioned\nST segment abnormalities are all new.\n\n" }, { "category": "ECG", "chartdate": "2151-08-17 00:00:00.000", "description": "Report", "row_id": 214828, "text": "Sinus bradycardia with sinus arrhythmia. Left atrial abnormality. Early\nprecordial QRS transition. Modest ST-T wave changes. Findings are\nnon-specific. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2127-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 956441, "text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evalf ro intterval chnage, PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with L hemothorax/rib fx\n REASON FOR THIS EXAMINATION:\n evalf ro intterval chnage, PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma. Rib fractures and hemothorax.\n\n AP supine radiograph of the chest. There are fractures involving the first\n seven left ribs with associated layering pleural effusion/blood as well as\n subpleural hemorrhagic collections laterally. Equivocal left mediastinal\n widening which is difficult to assess on this supine exam. Heart normal size\n without vascular congestion or consolidations. Satisfactorily positioned ET\n tube. NG tube is proximally positioned with its side hole probably in distal\n esophagus. Appearance is unchanged from exam 1.5 hours earlier on same day.\n\n" }, { "category": "Radiology", "chartdate": "2127-03-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 956428, "text": " 1:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall not moving any extrem\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man status post fall. Rule out bleeding.\n\n COMPARISON: No prior studies are available for comparison.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT CONTRAST: There is a large subdural hematoma along the\n convexity of the entire right cerebral hemisphere with a maximum width of 1.5\n cm. A small air bubble is seen within the subdural hematoma. In addition, a\n small subdural hematoma is seen on the left side. Bilateral subarachnoid\n hemorrhage is identified. 1.4-cm leftward subfalcine herniation is seen.\n There is diffuse effacement of the sulci with diffuse decreased density of the\n brain parenchyma consistent with edema. Mass effect on the right lateral\n ventricle. There is compression of the brainstem with central herniation.\n Pneumoencephaly is noted.\n\n Multiple fractures involving the left occipital, temporal, and zygoma.\n Fracture of the sphenoid bone is also noted. Fluid in the left mastoid cell\n is identified. Left hemotympanus. The left tympanic ossicles appear to be\n dislocated. Opacification of the sphenoid and ethmoidal sinuses. Minimal\n mucosal thickening on the left. There is a small air bubble in the right\n orbit, probably due to skull fracture.\n\n IMPRESSION:\n 1. Large subdural hematoma on the right and small on the left. Subarachnoid\n hemorrhage.\n 2. Central herniation.\n 3. Skull base fracture. Multiple fractures involving the occipital,\n temporal, and zygoma.\n 4. Left hemotympanus with apparent tympanic ossicle dislocation. Please\n correlate clinically.\n\n Findings were discussed with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-03-19 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 956429, "text": " 1:15 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall not moving any extrem\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man status post fall, rule out fracture.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Axial non-contrast helical scanning of the cervical spine was\n performed without IV contrast. Sagittal and coronal reconstructions were\n obtained.\n\n FINDINGS: Small left pneumothorax is noted. Subcutaneous emphysema is\n present in the anterior aspect of the lower neck. Endotracheal tube is seen\n as well as an NG tube. Right first rib fracture and left first, second, and\n third rib fractures.\n\n Left temporal fracture. No evidence of fractures involving the cervical spine.\n CT is not able to provide intrathecal detail comparable to MRI. The\n visualized outline of the thecal sac appears unremarkable.\n Opacification of the left mastoid cells and hemotympanum. The tympanic\n ossicles on the on the left side appear to be slightly distracted.\n\n IMPRESSION:\n 1. Small left pneumothorax.\n 2. Multiple rib fractures as described above.\n 3. No evidence of fractures involving the cervical spine.\n 4. Subcutaneous emphysema.\n 5. Left temporal bone fracture.\n 6. Opacification of the left mastoid cells and hemotympanum. The tympanic\n ossicles on the on the left side appear to be distrcted. Clinical correlation\n is recommended.\n\n Findings were discussed with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-03-19 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 956430, "text": " 1:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: r/o splenic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall not moving any extrem\n REASON FOR THIS EXAMINATION:\n r/o splenic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd WED 2:14 PM\n Left upper lobe pulmonary contusion. Multiple left rib fractures (), and\n small left hemothorax with adjacent atelectasis.\n\n No acute intra-abdominal abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male status post fall downstairs. Not moving any\n extremities.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired axial imaging from the thoracic inlet to the pubic\n symphysis after administration of 130 cc Optiray intravenous contrast. No\n oral contrast was administered. Multiplanar reformatted images obtained and\n reviewed.\n\n CT OF THE CHEST WITH IV CONTRAST: There are multiple left-sided rib\n fractures, involving ribs 1 through 6. There is an area of pulmonary\n contusion in the left upper lobe, measuring roughly 5 x 2 cm. There are\n scattered foci of ground glass attenuation more inferiorly in the left upper\n lobe which likely represent early areas of developing contusion. There is a\n small left-sided hemothorax, and adjacent compressive atelectasis. There is a\n small area of anterior mediastinal/retrosternal hematoma. There is mild\n dependent atelectasis on the right. The right lung is otherwise clear. There\n is a small bleb in the right upper lobe adjacent to the mediastinum.\n\n The heart and great vessels are normal. There is no pericardial effusion. The\n thoracic aorta is normal in caliber and contour. There is no significant\n mediastinal, hilar, or axillary lymphadenopathy. Endotracheal tube and\n nasogastric tube are in standard positions. The central bronchi are patent to\n the subsegmental level.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver enhances homogeneously. No\n focal hepatic lesions are seen. The gallbladder, spleen, pancreas, adrenal\n gland, stomach, and intra-abdominal loops of bowel are unremarkable.\n\n The kidneys enhance and excrete contrast symmetrically. The right kidney is\n unremarkable. There are few small rounded exophytic lesions off the left\n kidney, which likely represent cysts, but are too small to definitively\n characterize. There is no free air, free fluid, or pathologic mesenteric or\n retroperitoneal lymphadenopathy.\n (Over)\n\n 1:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: r/o splenic injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, and pelvic loops of\n bowel are unremarkable. Urinary bladder is partially decompressed, with a\n Foley catheter in place. The prostate is enlarged. There is no free pelvic\n fluid, and there is no abnormal pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: Notable for multiple left-sided rib fractures described above.\n There is probably an old right rib fracture as well. No suspicious lytic or\n sclerotic bony lesions are seen.\n\n IMPRESSION:\n\n 1) Multiple left-sided rib fractures, with adjacent pulmonary contusion in\n the left upper lobe, and small left hemothorax. Small anterior mediastinal\n hematoma.\n\n 2) No acute intra-abdominal abnormality.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2127-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 956426, "text": " 1:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall down 10 steps\n REASON FOR THIS EXAMINATION:\n injuries\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n AP bedside chest obtained supine. There are fractures involving the first\n seven ribs on the right with moderate displacement and associated pleural\n hemorrhage. There is possible mediastinal widening on the right (difficult\n assessment due to supine positioning and slight rotation). Therre is left\n pleural effusion/hemorrhage layering in supine positioning. I doubt the\n presence of pneumothorax, although this cannot be entirely excluded. Right\n lung clear. NG tube lies in proximal stomach with sidehole near GE junction.\n Normally positioned ET tube. Slightly angular lower thoracic/upper lumbar\n scoliosis may be positional but is noteworthy as regards possible spinal\n trauma. No consolidations or vascular congestion and heart not enlarged.\n\n IMPRESSION: Multiple upper left rib fractures and associated pleural\n hemorrhage/effusion. CT scan recommended to assess mediastinum.\n\n" }, { "category": "Radiology", "chartdate": "2127-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 956473, "text": " 5:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p L subclavian line, r/o ptx\n Admitting Diagnosis: SUBDURAL HEMATOMA/S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with subdural hematomaL hemothorax/rib fx\n\n REASON FOR THIS EXAMINATION:\n s/p L subclavian line, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural hematoma, left hemothorax and rib fracture status post\n line placement.\n\n COMPARISON: Comparison is made to study performed three hours earlier.\n\n PORTABLE CHEST RADIOGRAPH.\n\n Endotracheal tube seen with the tip approximately 5 cm above the carina.\n Nasogastric tube seen coursing over the stomach, tip not completely imaged on\n this study. A left subclavian line seen with the tip overlying the left upper\n mediastinum, possibly within a mediastinal vein vs. aorta. There has been a\n large interval increase in the size of the left hemothorax, with rightward\n shift of the mediastinum, trachea, and heart. Right lung remains relatively\n clear. Multiple left- sided rib fractures again identified.\n\n COMMENT: Findings discussed with Dr. at 6:15 p.m. who reports\n that the patient has expired.\n\n" }, { "category": "ECG", "chartdate": "2127-03-19 00:00:00.000", "description": "Report", "row_id": 226478, "text": "Atrial fibrillation with a rapid ventricular response and occasional\nventricular ectopic beats. Non-specific ST-T wave abnormalities, which may be\nbe in part, to the rapid rate. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2127-03-19 00:00:00.000", "description": "Report", "row_id": 1394892, "text": "resp care\nreceived from e.u s/p head trauma orally intubated and breathing spontaneously with Ve in high teens,abg within desired parameters.+bilateral coarse bs with brownish secretions. eventually required ac as pt's condition deteriorated. refer to flow sheet for data. pt expired.\n" }, { "category": "Nursing/other", "chartdate": "2127-03-19 00:00:00.000", "description": "Report", "row_id": 1394893, "text": "TSICU NPN Admission/event note 1600-1800\n67 YO M working on boat at cape, fell (12 feet) landing on head. Unable to intubate in field. Tx to OSH where pt was intubated and 1 pupil was blown. Tx to for further workup. Upon arrival, bilateral pupils blown. Scans showed: Bilateral SDH with shift, left sided skull fx, left sided hemothorax, rib fx's. Per neurosurgery, deemed non-operative. NEOB contact.\n\nUpon arrival to TSICU, HR Afib ranging 110-140's. Pt progessivly became hypotensive and tachycardic to 160's. Left radial arterial line and Left subclavian TLC placed per TSICU team. Pressors initiated and multiple fluid bolus given. Pt continued with low SBP into 40-60's. Epinephine given with little response. Pt's family memebers (two sons and wife) spoken to at this time about code status by TSICU team. Per family, pt would not want to have CPR initiated. At this time, pt made DNR, no further treatment given. Time of death 18:09.\n\nFamily support given by this RN, priest and social work called.\n" } ]

[ { "category": "Echo", "chartdate": "2186-04-14 00:00:00.000", "description": "Report", "row_id": 88156, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate LVOT gradient and coronary target anatomy during Ethanol ablation\nHeight: (in) 70\nWeight (lb): 178\nBSA (m2): 1.99 m2\nBP (mm Hg): 133/85\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 18:36\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nImaging done with 0.5 cc Definity to confirm corononary target. Patient\nmonitored during ethanol infusion .Outflow gradient demonstated with 20mcg\nDobutamine infusion on board ( negligible at rest)\n\nConclusions:\nSeptal perforator supplying basal anterior septum including the obstructing\nsegment identified by Definity. Peak outflow tract gradient during dobutamine\n10 mcg/kg/min was 80 mmHg, reduced to 36 mmHg post ethanol ablation with\ndobutamine 10 mcg/kg/min.\n\nThe LVOT gradient off inotropic stimulation was 12 mmHg prior to ethanol\nseptal ablation.\n\n\n" }, { "category": "Echo", "chartdate": "2186-04-14 00:00:00.000", "description": "Report", "row_id": 88157, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertrophic cardiomyopathy. Baseline\nHeight: (in) 70\nWeight (lb): 178\nBSA (m2): 1.99 m2\nBP (mm Hg): 143/83\nHR (bpm): 73\nStatus: Outpatient\nDate/Time: at 12:00\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\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF\n(>55%). Mild resting LVOT gradient. LVOT gradient increases with Valsalva.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No midsystolic\nclosure of aortic valve leaflets.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Normal mitral valve\nsupporting structures. of mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is small. Overall left ventricular\nsystolic function is normal (LVEF 70%). There is a mild resting left\nventricular outflow tract obstruction. The gradient increased with the\nValsalva manuever. The aortic arch is mildly dilated. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. Midsystolic closure of the aortic valve leaflets is not\nseen The mitral valve leaflets are structurally normal. There is no mitral\nvalve prolapse. There is systolic anterior motion of the mitral valve\nleaflets. Mild (1+) mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nImpression: mild resting left ventricular outflow tract obstruction; normal\nventricular function\n\n\n" }, { "category": "Echo", "chartdate": "2186-04-15 00:00:00.000", "description": "Report", "row_id": 91173, "text": "PATIENT/TEST INFORMATION:\nIndication: S/P Ethanol Ablation\nHeight: (in) 70\nWeight (lb): 178\nBSA (m2): 1.99 m2\nBP (mm Hg): 116/72\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 09:23\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: Moderate symmetric LVH. Mild 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.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. of the\nmitral chordae (normal variant). No resting LVOT gradient. of mitral valve\nleaflets. Mild (1+) MR.\n\nConclusions:\nThere is moderate symmetric left ventricular hypertrophy. There is a mild\nresting left ventricular outflow tract obstruction. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. There is systolic anterior motion of the mitral valve leaflets. Mild\n(1+) mitral regurgitation is seen.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar. There is mild LVH, with slightly more hypertrophy at the basal\nseptum, with a small resting gradient and systolic anterior motion of the\nmitral valve. Wall thicknesses may have been UNDERestimated on prior.\n\nTHIS STUDY WAS AMENDED ON DUE TO A TYPO IN THE PRIOR REPORT.\n\n\n" }, { "category": "Physician ", "chartdate": "2186-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730465, "text": "Chief Complaint:\n 24 Hour Events:\n -went into complete heart block on tele. EP evaluated. Has VVI pacing\n backup (currently set to VVI 30). If recovery of conduction does not\n occur, will need permanent pacemaker. Still in complete heart block\n this am on tele. Am EKG pending\n said give 1/2 dose disopyramide today , f/u with him for recs\n tomorrow.\n CK's peaked at 425, Trops still rising f/u am set.\n -On CIWA scale -not \n -moderate dyspnea y/d pm checked CXR, unchanged. dyspnea resolved.\n Echo: EF? 60% There is moderate symmetric left ventricular hypertrophy.\n There is a mild resting left ventricular outflow tract obstruction.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. There is\n systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral\n regurgitation is seen.\n Compared with the prior study (images reviewed) of , findings\n are similar. There is mild LVH, moder significant LVH at the basal\n septum, with a small resting gradient and systolic anterior motion of\n the mitral valve. Wall thicknesses may have been UNDERestimated on\n prior.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 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: 36.6\nC (97.8\n HR: 46 (42 - 81) bpm\n BP: 104/62(72) {88/43(46) - 131/82(97)} mmHg\n RR: 20 (8 - 23) insp/min\n SpO2: 96%\n Heart rhythm: 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,845 mL\n 197 mL\n PO:\n 1,300 mL\n 60 mL\n TF:\n IVF:\n 545 mL\n 137 mL\n Blood products:\n Total out:\n 3,800 mL\n 0 mL\n Urine:\n 3,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,955 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI late peaking crescendo-decrescendo\n murmur at LSB, augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n 43yo M with hypertrophic cardiomyopathy s/p alcohol septal ablation who\n did well with respect to reduction in gradient, but procedure was\n complicated by transient AV block s/p temporary pacing wire now in\n complete heart block.\n .\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours, set VVI 30 MA 2.\n - heparin gtt while temp wire in place (goal PTT 50)\n - check pacing wire at rounds. daily to check threshold. Most recently\n 0.4.\n -consider permanent pacemaker if does not revert within 24 hours.\n appreciate EP recs.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Nursing", "chartdate": "2186-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730643, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n This am, patient attempted to lift himself up in bed and immediately\n felt pain in R groin- R groin oozing bright red blood-> pressure held-\n CCU team notified & in- pressure held until bleeding stopped, then\n pressure dsg applied- EP in-> temp pacer check- pacer appropriately\n sensing and capturing- small R groin hematoma- (+) distal pulses.\n Action:\n Heparin gtt held X2hrs then resumed @ 1050u/hr- PTT pending- NPO after\n 12am- Percocet 1 tab X2 given for back pain related to being in bed x3\n days- freq back care & repositioning.\n Response:\n No further bleeding from R groin- good effect noted from percocet.\n Plan:\n Perm pacer/defib placement tomorrow.\n" }, { "category": "Physician ", "chartdate": "2186-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730451, "text": "Chief Complaint:\n 24 Hour Events:\n -went into complete heart block on tele. EP evaluated. Has VVI pacing\n backup (currently set to VVI 30). If recovery of conduction does not\n occur, will need permanent pacemaker. Still in complete heart block\n this am on tele. Am EKG pending\n said give 1/2 dose disopyramide today , f/u with him for recs\n tomorrow.\n CK's peaked at 425, Trops still rising f/u am set.\n -On CIWA scale -not \n -moderate dyspnea y/d pm checked CXR, unchanged. dyspnea resolved.\n Echo: EF? 60% There is moderate symmetric left ventricular hypertrophy.\n There is a mild resting left ventricular outflow tract obstruction.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. There is\n systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral\n regurgitation is seen.\n Compared with the prior study (images reviewed) of , findings\n are similar. There is mild LVH, moder significant LVH at the basal\n septum, with a small resting gradient and systolic anterior motion of\n the mitral valve. Wall thicknesses may have been UNDERestimated on\n prior.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 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: 36.6\nC (97.8\n HR: 46 (42 - 81) bpm\n BP: 104/62(72) {88/43(46) - 131/82(97)} mmHg\n RR: 20 (8 - 23) insp/min\n SpO2: 96%\n Heart rhythm: 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,845 mL\n 197 mL\n PO:\n 1,300 mL\n 60 mL\n TF:\n IVF:\n 545 mL\n 137 mL\n Blood products:\n Total out:\n 3,800 mL\n 0 mL\n Urine:\n 3,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,955 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730454, "text": "Chief Complaint:\n 24 Hour Events:\n -went into complete heart block on tele. EP evaluated. Has VVI pacing\n backup (currently set to VVI 30). If recovery of conduction does not\n occur, will need permanent pacemaker. Still in complete heart block\n this am on tele. Am EKG pending\n said give 1/2 dose disopyramide today , f/u with him for recs\n tomorrow.\n CK's peaked at 425, Trops still rising f/u am set.\n -On CIWA scale -not \n -moderate dyspnea y/d pm checked CXR, unchanged. dyspnea resolved.\n Echo: EF? 60% There is moderate symmetric left ventricular hypertrophy.\n There is a mild resting left ventricular outflow tract obstruction.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. There is\n systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral\n regurgitation is seen.\n Compared with the prior study (images reviewed) of , findings\n are similar. There is mild LVH, moder significant LVH at the basal\n septum, with a small resting gradient and systolic anterior motion of\n the mitral valve. Wall thicknesses may have been UNDERestimated on\n prior.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 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: 36.6\nC (97.8\n HR: 46 (42 - 81) bpm\n BP: 104/62(72) {88/43(46) - 131/82(97)} mmHg\n RR: 20 (8 - 23) insp/min\n SpO2: 96%\n Heart rhythm: 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,845 mL\n 197 mL\n PO:\n 1,300 mL\n 60 mL\n TF:\n IVF:\n 545 mL\n 137 mL\n Blood products:\n Total out:\n 3,800 mL\n 0 mL\n Urine:\n 3,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,955 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n 43yo M with hypertrophic cardiomyopathy s/p alcohol septal ablation who\n did well with respect to reduction in gradient, but procedure was\n complicated by transient AV block s/p temporary pacing wire now in\n complete heart block.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730455, "text": "Chief Complaint:\n 24 Hour Events:\n -went into complete heart block on tele. EP evaluated. Has VVI pacing\n backup (currently set to VVI 30). If recovery of conduction does not\n occur, will need permanent pacemaker. Still in complete heart block\n this am on tele. Am EKG pending\n said give 1/2 dose disopyramide today , f/u with him for recs\n tomorrow.\n CK's peaked at 425, Trops still rising f/u am set.\n -On CIWA scale -not \n -moderate dyspnea y/d pm checked CXR, unchanged. dyspnea resolved.\n Echo: EF? 60% There is moderate symmetric left ventricular hypertrophy.\n There is a mild resting left ventricular outflow tract obstruction.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. There is\n systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral\n regurgitation is seen.\n Compared with the prior study (images reviewed) of , findings\n are similar. There is mild LVH, moder significant LVH at the basal\n septum, with a small resting gradient and systolic anterior motion of\n the mitral valve. Wall thicknesses may have been UNDERestimated on\n prior.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 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: 36.6\nC (97.8\n HR: 46 (42 - 81) bpm\n BP: 104/62(72) {88/43(46) - 131/82(97)} mmHg\n RR: 20 (8 - 23) insp/min\n SpO2: 96%\n Heart rhythm: 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,845 mL\n 197 mL\n PO:\n 1,300 mL\n 60 mL\n TF:\n IVF:\n 545 mL\n 137 mL\n Blood products:\n Total out:\n 3,800 mL\n 0 mL\n Urine:\n 3,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,955 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema.\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n 43yo M with hypertrophic cardiomyopathy s/p alcohol septal ablation who\n did well with respect to reduction in gradient, but procedure was\n complicated by transient AV block s/p temporary pacing wire now in\n complete heart block.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730457, "text": "Chief Complaint:\n 24 Hour Events:\n -went into complete heart block on tele. EP evaluated. Has VVI pacing\n backup (currently set to VVI 30). If recovery of conduction does not\n occur, will need permanent pacemaker. Still in complete heart block\n this am on tele. Am EKG pending\n said give 1/2 dose disopyramide today , f/u with him for recs\n tomorrow.\n CK's peaked at 425, Trops still rising f/u am set.\n -On CIWA scale -not \n -moderate dyspnea y/d pm checked CXR, unchanged. dyspnea resolved.\n Echo: EF? 60% There is moderate symmetric left ventricular hypertrophy.\n There is a mild resting left ventricular outflow tract obstruction.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. There is\n systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral\n regurgitation is seen.\n Compared with the prior study (images reviewed) of , findings\n are similar. There is mild LVH, moder significant LVH at the basal\n septum, with a small resting gradient and systolic anterior motion of\n the mitral valve. Wall thicknesses may have been UNDERestimated on\n prior.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 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: 36.6\nC (97.8\n HR: 46 (42 - 81) bpm\n BP: 104/62(72) {88/43(46) - 131/82(97)} mmHg\n RR: 20 (8 - 23) insp/min\n SpO2: 96%\n Heart rhythm: 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,845 mL\n 197 mL\n PO:\n 1,300 mL\n 60 mL\n TF:\n IVF:\n 545 mL\n 137 mL\n Blood products:\n Total out:\n 3,800 mL\n 0 mL\n Urine:\n 3,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,955 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema.\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n 43yo M with hypertrophic cardiomyopathy s/p alcohol septal ablation who\n did well with respect to reduction in gradient, but procedure was\n complicated by transient AV block s/p temporary pacing wire now in\n complete heart block.\n .\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours, set VVI 30 MA 2.\n - heparin gtt while temp wire in place (goal PTT 50)\n - check pacing wire at rounds. daily to check threshold. Most recently\n 0.4.\n -consider permanent pacemaker\n appreciate EP recs.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Physician ", "chartdate": "2186-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730545, "text": "Chief Complaint:\n 24 Hour Events:\n -went into complete heart block on tele. EP evaluated. Has VVI pacing\n backup (currently set to VVI 30). If recovery of conduction does not\n occur, will need permanent pacemaker. Still in complete heart block\n this am on tele. Am EKG pending\n said give 1/2 dose disopyramide today , f/u with him for recs\n tomorrow.\n CK's peaked at 425, Trops still rising f/u am set.\n -On CIWA scale -not \n -moderate dyspnea y/d pm checked CXR, unchanged. dyspnea resolved.\n Echo: EF? 60% There is moderate symmetric left ventricular hypertrophy.\n There is a mild resting left ventricular outflow tract obstruction.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. There is\n systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral\n regurgitation is seen.\n Compared with the prior study (images reviewed) of , findings\n are similar. There is mild LVH, moder significant LVH at the basal\n septum, with a small resting gradient and systolic anterior motion of\n the mitral valve. Wall thicknesses may have been UNDERestimated on\n prior.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 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: 36.6\nC (97.8\n HR: 46 (42 - 81) bpm\n BP: 104/62(72) {88/43(46) - 131/82(97)} mmHg\n RR: 20 (8 - 23) insp/min\n SpO2: 96%\n Heart rhythm: 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,845 mL\n 197 mL\n PO:\n 1,300 mL\n 60 mL\n TF:\n IVF:\n 545 mL\n 137 mL\n Blood products:\n Total out:\n 3,800 mL\n 0 mL\n Urine:\n 3,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,955 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI late peaking crescendo-decrescendo\n murmur at LSB, augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n 43yo M with hypertrophic cardiomyopathy s/p alcohol septal ablation who\n did well with respect to reduction in gradient, but procedure was\n complicated by transient AV block s/p temporary pacing wire now in\n complete heart block.\n .\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours, set VVI 30 MA 2.\n - heparin gtt while temp wire in place (goal PTT 50)\n - check pacing wire at rounds. daily to check threshold. Most recently\n 0.4.\n -consider permanent pacemaker if does not revert within 24 hours.\n appreciate EP recs.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n ------ Protected Section ------\n CCU Attending Progress Note\n I agree with the detailed note by Dr. delineated today.\n History and Physical. I agree with the documented history and\n physical examination. I concur with the treatment plan outlined\n above.\n Medical Decision Making. Mr. septal ablation\n with alcohol on Friday. He has done well with a reduction of the\n gradient but has developed complete heart block. EP plans for\n permanent pacemaker placement and ICD placement this week. A small\n groin hematoma has been managed conservatively. We will continue CCU\n care pending placement of his PPM. We are restarting disopyrimide and\n verapamil at reduced dosages.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 12:59 ------\n" }, { "category": "Nursing", "chartdate": "2186-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730676, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730941, "text": "cardiomyopathy, Hypertrophic s/p ETOH ablation c/b complete heart block\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730627, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n This am, patient attempted to lift himself up in bed and immediately\n felt pain in R groin- R groin oozing bright red blood-> pressure held-\n CCU team notified & in- pressure held until bleeding stopped, then\n pressure dsg applied- EP in-> temp pacer check- pacer appropriately\n sensing and capturing.\n Action:\n Heparin gtt held X2hrs then resumed @ 1050u/hr- PTT pending- NPO after\n 12am- Percocet 1 tab X2 given for back pain related to being in bed x3\n days- freq back care & repositioning.\n Response:\n No further bleeding from R groin- good effect noted from percocet.\n Plan:\n Perm pacer/defib placement tomorrow.\n" }, { "category": "Nursing", "chartdate": "2186-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730625, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n This am, patient attempted to lift himself up in bed and immediately\n felt pain in R groin- R groin oozing bright red blood-> pressure held-\n CCU team notified & in- pressure held until bleeding stopped, then\n pressure dsg applied- EP in-> temp pacer check- pacer appropriately\n sensing and capturing.\n Action:\n Heparin gtt held X2hrs then resumed @ 1050u/hr- PTT pending- NPO after\n 12am\n Response:\n No further bleeding from R groin.\n Plan:\n Perm pacer/defib placement tomorrow.\n" }, { "category": "Physician ", "chartdate": "2186-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 731063, "text": "Chief Complaint:\n 24 Hour Events:\n Heparin drip stopped.\n Pt had been symptomatic with bradycardia, pacer reset from 30 to 60.\n V- pacing on Tele\n - complained of right knee pain, no trauma, no prior hx; exam\n unremarkable; got ibuprofen and Percocet,\n Has pain with movement only\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 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: 36.6\nC (97.9\n HR: 60 (35 - 66) bpm\n BP: 104/62(72) {97/51(62) - 122/93(98)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 83 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,440 mL\n 64 mL\n PO:\n 1,050 mL\n TF:\n IVF:\n 390 mL\n 64 mL\n Blood products:\n Total out:\n 2,750 mL\n 650 mL\n Urine:\n 2,750 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,310 mL\n -586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GENERAL: NAD.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n Right knee: TTP in suprapatellar region, no effusion, no erythema,\n limited ROM pain, but worse with plantar extension, internal\n rotation\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 178 K/uL\n 12.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 16 mg/dL\n 104 mEq/L\n 139 mEq/L\n 37.1 %\n 7.5 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n 04:46 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n 7.5\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n 37.1\n Plt\n 89\n 178\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n 1.0\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n 102\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HEART BLOCK, COMPLETE (CHB)\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n .\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by complete heart block, bradycardia s/p temporary pacing wire.\n .\n # Complete Heart Block: Complication of septal ablation. Persistent.\n - continue demand rate at 60 due to symptomatic bradycardia\n -heparin GTT dc\n - check pacing wire at rounds daily to check threshold. Most recently\n 0.4.\n - appreciate EP recs\n - plan for ICD implantation in a.m.; has been NPO after midnight\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Right knee pain\n None without movement\n Hold motrin periop, Percocet PRN\n Consider plain films post op.\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet; NPO after midnight for ICD implantation\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin SC; d/c heparin at 2 a.m. for pacemaker implantation\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730318, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730998, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for permanent pacer/ICD schedule for today,\n .\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with temp transvenous pacer, wires intact, no bleeding from\n right groin site. Continuously v-paced at a rate of 60. BP\n 100-110/50-60\ns. Denying any SOB, CP, dizziness. No edema noted, skin\n warm, pulses palpable throughout. Voiding adequate amounts of yellow\n urine Sp02 92-94% on RA, RR 8-12. Lungs clear. Abdomen soft with good\n bowel sounds. NPO after MN for procedure. Denying any pain.\n Action:\n Placed pt on 2 L NC at 0200 after Sp02 dropped below 90% during sleep,\n pt denied any SOB, CP, difficulty breathing. Maintained integrity of\n temp pacer. Kept pt NPO after MN, enforced bedrest. Held 0600 sc\n heparin for procedure.\n Response:\n Pt slept whole night. Continues to be v-paced at 60 BPM. Temp pacer\n wires intact, dsg intact. BP stable. UO adequate. Sp02 94-95% on 2 L NC\n during deep sleep, increases to high 90\ns when awake.\n Plan:\n Scheduled for perm pacer today, time unclear. Hemodynamic monitoring.\n" }, { "category": "Nursing", "chartdate": "2186-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730374, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2186-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730784, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - had some bleeding/pain in groin site after pulling himself up in bed\n - resolved with pressure\n - repeat CXR: As compared to the previous radiograph, the lung volumes\n have slightly decreased, likely to reflect a lesser inspiratory effort.\n The position of the pacing line is unchanged. Borderline size of the\n cardiac silhouette without evidence of pulmonary edema. No pleural\n effusions, no focal parenchymal opacities suggesting pneumonia.\n - did not get disopyramide dose, did not hear from Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 35 (30 - 55) bpm\n BP: 97/48(60) {93/48(60) - 127/70(80)} mmHg\n RR: 14 (10 - 23) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 544 mL\n 284 mL\n PO:\n 60 mL\n 120 mL\n TF:\n IVF:\n 484 mL\n 164 mL\n Blood products:\n Total out:\n 2,000 mL\n 800 mL\n Urine:\n 2,000 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,456 mL\n -516 mL\n Respiratory support\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI late peaking crescendo-decrescendo\n murmur at LSB, augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 189 K/uL\n 13.5 g/dL\n 111 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 14 mg/dL\n 105 mEq/L\n 141 mEq/L\n 37.1 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n Plt\n 89\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours, set VVI 30 MA 2.\n - heparin gtt while temp wire in place (goal PTT 50)\n - check pacing wire at rounds. daily to check threshold. Most recently\n 0.4.\n -consider permanent pacemaker if does not revert within 24 hours.\n appreciate EP recs.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730995, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for permanent pacer/ICD schedule for today,\n .\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with temp transvenous pacer, wires intact, right groin site\n with soft hematoma. Continuously v-paced at a rate of 60. BP\n 100-110/50-60\ns. Voiding adequate amounts of yellow urine. Denying any\n SOB, CP, dizziness. No edema noted, pulses palpable throughout, LE\n cool. Sp02 low 92-94% on RA. Lungs clear. Abdomen soft with good bowel\n sounds. NPO after MN for procedure.\n Action:\n Placed pt on 2 L NC at 0200 after Sp02 dropped below 90% during sleep,\n pt denied any SOB, CP, difficulty breathing. Maintained integrity of\n temp pacer. Kept pt NPO after MN, enforced bedrest.\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n" }, { "category": "Physician ", "chartdate": "2186-04-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730304, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -Had 3/10 chest pain overnight. Got morphine 1 mg IV. 30 minutes later,\n nauseas, SBP decreased to 80-90s. Exam otherwise unremarkable. Pulsus\n 4. Gave Zofran 4 mg IV + NS 250 cc, with improvement in symptoms.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Morphine Sulfate - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 58 (55 - 90) bpm\n BP: 125/81(91) {82/48(58) - 128/90(98)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 957 mL\n 197 mL\n PO:\n 600 mL\n TF:\n IVF:\n 357 mL\n 197 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 957 mL\n -403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema.\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/47.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours\n - heparin gtt while temp wire in place (goal PTT 50)\n - check pacing wire at 10 a.m. and 10 p.m. daily to check threshold.\n Most recently 0.4.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n ------ Protected Section ------\n CCU Attending Progress Note\n I agree with the detailed note by Dr. delineated today.\n History and Physical. I agree with the documented history and\n physical examination. I concur with the treatment plan outlined\n above.\n Medical Decision Making. Mr. septal ablation\n yesterday with alcohol. Has has done well with a reduction of the\n gradient but has now developed complete heart block. We will ask EP to\n consult about the need for permanent pacemaker placement.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 16:37 ------\n" }, { "category": "Consult", "chartdate": "2186-04-15 00:00:00.000", "description": "EP Initial Consult Note", "row_id": 730307, "text": "Consult requested by: CCU Service\n Chief Complaint: Complete Heart Block\n HPI:\n Mr. is 43 years old with hypertrophic\n cardiomyopathy. He was diagnosed 3 years ago after experiencing severe\n exertional dyspnea. Recent echocardiogram revealed asymmetric LV\n septal hypertrophy with LV septum measuring 17mm. LVOT gradient was\n inducible to 125 mm Hg. His symptoms progressed to NYHA Class III. He\n had been treated medically with disopyramide 300 mg and complained\n of anticholinergic side effects related to this treatment.\n Yesterday he underwent alcohol septal ablation with contrast\n echocardiographic guidance. Preablation LVOT gradient on 10 mg\n dobutamine measured 120 mm Hg, which subsequently decreased to 60 mm Hg\n after the procedure.\n We are asked to consult in the setting of post operative complete heart\n block.\n Patient admitted from: Home\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Other medications:\n Past medical history:\n Family history:\n Social history:\n Hypercholesterolemia\n Mild to moderate MR anterior motion of the mitral valve\n leaflet\n GERD\n No family history of hypertrophic cardiomyopathy. No history of sudden\n death.\n Father died at age 41 of suicide.\n Occupation: Sales\n Drugs: No\n Tobacco: Intermittent\n Alcohol: Social\n Other:\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Respiratory: Dyspnea\n Flowsheet Data as of 04:43 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 49 (42 - 90) bpm\n BP: 112/66(76) {82/48(58) - 131/90(98)} mmHg\n RR: 20 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm), 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 957 mL\n 385 mL\n PO:\n 600 mL\n TF:\n IVF:\n 357 mL\n 385 mL\n Blood products:\n Total out:\n 0 mL\n 1,600 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 957 mL\n -1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: ), Soft\n S2, Late murmur over precordium with soft apical MR murmur;\n PMI nondisplaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n ECG: Sinus rhythm 100 bpm with complete heart block; ventricular escape\n of 46 bpm with morphology. QRS duration of 120 ms \n of the R wave intrinsicoid in multiple leads.\n With RV pacing at 60 bpm, no retrograde VA conduction observed.\n Assessment and Plan\n Mr. is a 43 year old man with hypertrophic cardiomyopathy\n and significant exertional limitation who underwent alcohol septal\n ablation yesterday. Preprocedure ECG sinus with PR 164 and QRS 94\n ms. procedure ECG shows significant PR prolongation with RBBB and\n LAFB. Current ECG shows complete heart block with QRS duration >120\n ms morphology.\n Will continue telemetry observation with VVI pacing backup (currently\n set to VVI 30 with appropriate threshold).\n If recovery of conduction does not occur will need permanent\n pacemaker/ICD.\n MD\n EP Fellow\n" }, { "category": "Nursing", "chartdate": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730354, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received patient w/ venous temp wire attached/intact- pacemaker\n appropriately sensing and capturing- Tele: 1^st and 2^nd AVB noted this\n am- CHB this pm- R groin site intact- (+) palp distal pulses-\n hemodynamically stable- c/o chest pressure X2 today & SOB w/ exertion-\n good U/O.\n Action:\n Seen by EP- CXR done- Mg 1.8 mag sulfate 2gm IV given- started on\n norpace 300mg Po X1 @ 1730- heparin gtt @ 1050u/hr- emotional support\n given.\n Response:\n CCU & EP physicians spoke w/ patient re: permanent pacemaker/defib\n placement- repeat PTT @ goal 59.8\n Plan:\n Follow labs- ? need for pacer on Monday.\n" }, { "category": "Nursing", "chartdate": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730356, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received patient w/ venous temp wire attached/intact- pacemaker\n appropriately sensing and capturing- Tele: 1^st and 2^nd AVB noted this\n am- CHB this pm- R groin site intact- (+) palp distal pulses-\n hemodynamically stable- c/o chest pressure X2 today & SOB w/ exertion-\n good U/O.\n Action:\n Seen by EP- CXR done- Mg 1.8 mag sulfate 2gm IV given- started on\n norpace 300mg Po X1 @ 1730- heparin gtt @ 1050u/hr- emotional support\n given.\n Response:\n CCU & EP physicians spoke w/ patient re: permanent pacemaker/defib\n placement- repeat PTT @ goal 59.8\n Plan:\n Follow labs- ? need for pacer on Monday.\n" }, { "category": "Nursing", "chartdate": "2186-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730411, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Pt remains in 3\n AVB- rate 47-50 w stable BP. Temporary TV pacer on\n standby- rate 30/ mA-2.\n Action:\n Close monitoring of hemodynamics, rhythym this shift. Assisted w\n frequent need to turn/ backrubs for back discomfort. Reinforced need\n for pt to call for any need to change position and to keep rt leg\n straight. Pulses/groin site w temp wire- continues to be stable.\n Remains on heparin gtt 1050u w therapeutic PTT-59. Teaching, support\n for pt, awaiting probable permanent pacer/ICD Monday.\n Response:\n Pt appears to understand indication for permanent device placement.\n Continues to move on own in spite of encouragement to RN for any\n shift in positioning w leg needing to be still/straight w femoral wire\n in place. Pt remains in 3\n AVB but stable BP. Pacer on standby at rate\n 30 per EPS- but no need to fire/capture this shift. Appears to be\n sensing WNL. Groin site D/I no hemotoma and pulses all (+).\n Plan:\n Continue to provide pt w comfort/decrease anxiety/teaching re:\n pacer/ICD placement as planned for Monday. Continue to closely monitor\n hemodynamics- continue to maintain pacer on standby at rate 30 as\n ordered. Check AM labs- replete lytes as needed- keep PTT WNL /maintain\n therapeutic heparin dosage. Keep pt aware of plan of care.\n" }, { "category": "Physician ", "chartdate": "2186-04-17 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 730817, "text": "TITLE: EP Follow-Up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: - Increased frequency of pacing\n - Thresold on temp wire 1.5-2 mA, set at 4.0 mA\n - no c/o, no other events\n Medications\n Unchanged\n ASA 325 mg daily\n Heparin IV SS\n Physical Exam\n General appearance: NAD, appears well lying in bed\n BP: 104 / 52 mmHg\n HR: 35 bpm\n RR: 19 insp/min\n Tmax C last 24 hours: 37.1 C\n Tmax F last 24 hours: 98.7 F\n T current C: 36.3 C\n T current F: 97.3 F\n O2 sat: 98 % on Room air\n Previous day:\n Intake: 544 mL\n Output: 2,000 mL\n Fluid balance: -1,456 mL\n Today:\n Weight: 83 kg\n Intake: 318 mL\n Output: 900 mL\n Fluid balance: -582 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND), (Auscultation: +BS)\n Extremities:\n Femoral exam: right sided temp wire with pressure dressing\n Labs\n 189\n 13.5\n 111\n 1.1\n 27\n 4.3\n 14\n 105\n 141\n 37.1\n 8.7\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 02:23 PM\n 05:33 AM\n 05:54 PM\n 04:51 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n Hgb\n 14.4\n 14.3\n 13.6\n 13.5\n Hct (Serum)\n 41.0\n 39.7\n 39.4\n 37.1\n Plt\n 89\n INR\n 1.0\n 1.0\n PTT\n 47.8\n 59.8\n 46.4\n 41.5\n 50.1\n Na+\n 137\n 140\n 141\n 141\n K + (Serum)\n 3.6\n 4.0\n 4.2\n 4.3\n Cl\n 101\n 109\n 105\n 105\n HCO3\n 25\n 22\n 27\n 27\n BUN\n 17\n 15\n 13\n 14\n Creatinine\n 1.1\n 0.9\n 1.2\n 1.1\n Glucose\n 120\n 104\n 103\n 111\n CK\n \n CK-MB\n 51\n 40\n 9\n Troponin T\n 0.48\n 0.67\n 0.91\n ABG: / / / 27 / Values as of 04:51 AM\n Tests\n Telemetry: CHB with occassional LBBB-pattern escape\n Assessment and Plan\n 43 year old M with HOCM s/p ETOH septal ablation and ASMI now c/b CHB\n with unreliable LBBB escape, utilizing temp wire with increased\n frequency overnight.\n 1. AV block: High grade\n -Continue bedrest with temp pacing required via right groin\n -Plan PPM in am (?ICD per DR. )\n -NPO at midnight, d/c heparin at 2am for procedure in am\n Will d/w Dr. and Dr. \n" }, { "category": "Physician ", "chartdate": "2186-04-17 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 730818, "text": "TITLE: EP Follow-Up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: - Increased frequency of pacing\n - Thresold on temp wire 1.5-2 mA, set at 4.0 mA\n - no c/o, no other events\n Medications\n Unchanged\n ASA 325 mg daily\n Heparin IV SS\n Physical Exam\n General appearance: NAD, appears well lying in bed\n BP: 104 / 52 mmHg\n HR: 35 bpm\n RR: 19 insp/min\n Tmax C last 24 hours: 37.1 C\n Tmax F last 24 hours: 98.7 F\n T current C: 36.3 C\n T current F: 97.3 F\n O2 sat: 98 % on Room air\n Previous day:\n Intake: 544 mL\n Output: 2,000 mL\n Fluid balance: -1,456 mL\n Today:\n Weight: 83 kg\n Intake: 318 mL\n Output: 900 mL\n Fluid balance: -582 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND), (Auscultation: +BS)\n Extremities:\n Femoral exam: right sided temp wire with pressure dressing\n Labs\n 189\n 13.5\n 111\n 1.1\n 27\n 4.3\n 14\n 105\n 141\n 37.1\n 8.7\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 02:23 PM\n 05:33 AM\n 05:54 PM\n 04:51 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n Hgb\n 14.4\n 14.3\n 13.6\n 13.5\n Hct (Serum)\n 41.0\n 39.7\n 39.4\n 37.1\n Plt\n 89\n INR\n 1.0\n 1.0\n PTT\n 47.8\n 59.8\n 46.4\n 41.5\n 50.1\n Na+\n 137\n 140\n 141\n 141\n K + (Serum)\n 3.6\n 4.0\n 4.2\n 4.3\n Cl\n 101\n 109\n 105\n 105\n HCO3\n 25\n 22\n 27\n 27\n BUN\n 17\n 15\n 13\n 14\n Creatinine\n 1.1\n 0.9\n 1.2\n 1.1\n Glucose\n 120\n 104\n 103\n 111\n CK\n \n CK-MB\n 51\n 40\n 9\n Troponin T\n 0.48\n 0.67\n 0.91\n ABG: / / / 27 / Values as of 04:51 AM\n Tests\n Telemetry: CHB with occassional LBBB-pattern escape\n Assessment and Plan\n 43 year old M with HOCM s/p ETOH septal ablation and ASMI now c/b CHB\n with unreliable LBBB escape, utilizing temp wire with increased\n frequency overnight.\n 1. AV block: High grade\n -Continue bedrest with temp pacing required via right groin\n -Plan PPM in am (?ICD per DR. )\n -NPO at midnight, d/c heparin at 2am for procedure in am\n Will d/w Dr. and Dr. \n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730993, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for ICD placement today.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with transvenous pacer, v-paced at a rate of 60,\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n" }, { "category": "Physician ", "chartdate": "2186-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 731044, "text": "Chief Complaint:\n 24 Hour Events:\n Heparin drip stopped.\n Temp pacemaker pacing at 60\nTelemetry\n - complained of knee pain; exam unremarkable; got ibuprofen and\n Percocet\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 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: 36.6\nC (97.9\n HR: 60 (35 - 66) bpm\n BP: 104/62(72) {97/51(62) - 122/93(98)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 83 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,440 mL\n 64 mL\n PO:\n 1,050 mL\n TF:\n IVF:\n 390 mL\n 64 mL\n Blood products:\n Total out:\n 2,750 mL\n 650 mL\n Urine:\n 2,750 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,310 mL\n -586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\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 178 K/uL\n 12.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 16 mg/dL\n 104 mEq/L\n 139 mEq/L\n 37.1 %\n 7.5 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n 04:46 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n 7.5\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n 37.1\n Plt\n 89\n 178\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n 1.0\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n 102\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HEART BLOCK, COMPLETE (CHB)\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 731045, "text": "Chief Complaint:\n 24 Hour Events:\n Heparin drip stopped.\n Temp pacemaker pacing at 60\nTelemetry\n - complained of knee pain; exam unremarkable; got ibuprofen and\n Percocet\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 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: 36.6\nC (97.9\n HR: 60 (35 - 66) bpm\n BP: 104/62(72) {97/51(62) - 122/93(98)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 83 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,440 mL\n 64 mL\n PO:\n 1,050 mL\n TF:\n IVF:\n 390 mL\n 64 mL\n Blood products:\n Total out:\n 2,750 mL\n 650 mL\n Urine:\n 2,750 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,310 mL\n -586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\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 178 K/uL\n 12.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 16 mg/dL\n 104 mEq/L\n 139 mEq/L\n 37.1 %\n 7.5 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n 04:46 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n 7.5\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n 37.1\n Plt\n 89\n 178\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n 1.0\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n 102\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HEART BLOCK, COMPLETE (CHB)\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n S/p septal ablation now in CHB. Temporary pacer rate increased to 60\n BPM given symptoms with slower heart rate. Plan for PPM tomorrow.\n Patient care time critical care 30 minutes for management of complete\n heart block, bradycardia and temporary pacemaker.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 731047, "text": "Chief Complaint:\n 24 Hour Events:\n Heparin drip stopped.\n Temp pacemaker pacing at 60\nTelemetry\n - complained of knee pain; exam unremarkable; got ibuprofen and\n Percocet\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 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: 36.6\nC (97.9\n HR: 60 (35 - 66) bpm\n BP: 104/62(72) {97/51(62) - 122/93(98)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 83 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,440 mL\n 64 mL\n PO:\n 1,050 mL\n TF:\n IVF:\n 390 mL\n 64 mL\n Blood products:\n Total out:\n 2,750 mL\n 650 mL\n Urine:\n 2,750 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,310 mL\n -586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GENERAL: NAD.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 178 K/uL\n 12.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 16 mg/dL\n 104 mEq/L\n 139 mEq/L\n 37.1 %\n 7.5 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n 04:46 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n 7.5\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n 37.1\n Plt\n 89\n 178\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n 1.0\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n 102\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HEART BLOCK, COMPLETE (CHB)\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n S/p septal ablation now in CHB. Temporary pacer rate increased to 60\n BPM given symptoms with slower heart rate. Plan for PPM tomorrow.\n Patient care time critical care 30 minutes for management of complete\n heart block, bradycardia and temporary pacemaker.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 731048, "text": "Chief Complaint:\n 24 Hour Events:\n Heparin drip stopped.\n Temp pacemaker pacing at 60\nTelemetry\n - complained of knee pain; exam unremarkable; got ibuprofen and\n Percocet\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 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: 36.6\nC (97.9\n HR: 60 (35 - 66) bpm\n BP: 104/62(72) {97/51(62) - 122/93(98)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 83 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 1,440 mL\n 64 mL\n PO:\n 1,050 mL\n TF:\n IVF:\n 390 mL\n 64 mL\n Blood products:\n Total out:\n 2,750 mL\n 650 mL\n Urine:\n 2,750 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,310 mL\n -586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GENERAL: NAD.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 178 K/uL\n 12.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 16 mg/dL\n 104 mEq/L\n 139 mEq/L\n 37.1 %\n 7.5 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n 04:46 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n 7.5\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n 37.1\n Plt\n 89\n 178\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n 1.0\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n 102\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HEART BLOCK, COMPLETE (CHB)\n .H/O CARDIOMYOPATHY, HYPERTROPHIC\n .\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by complete heart block, bradycardia s/p temporary pacing wire.\n .\n # Complete Heart Block: Complication of septal ablation. Persistent.\n - increased demand rate to 60 due to symptomatic bradycardia\n -heparin GTT dc\n - check pacing wire at rounds daily to check threshold. Most recently\n 0.4.\n - appreciate EP recs\n - plan for ICD implantation in a.m.; has been NPO after midnight\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet; NPO after midnight for ICD implantation\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin SC; d/c heparin at 2 a.m. for pacemaker implantation\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 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": "2186-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730911, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - had some bleeding/pain in groin site after pulling himself up in bed\n - resolved with pressure\n - repeat CXR: As compared to the previous radiograph, the lung volumes\n have slightly decreased, likely to reflect a lesser inspiratory effort.\n The position of the pacing line is unchanged. Borderline size of the\n cardiac silhouette without evidence of pulmonary edema. No pleural\n effusions, no focal parenchymal opacities suggesting pneumonia.\n - did not get disopyramide dose, did not hear from Dr. \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 35 (30 - 55) bpm\n BP: 97/48(60) {93/48(60) - 127/70(80)} mmHg\n RR: 14 (10 - 23) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 544 mL\n 284 mL\n PO:\n 60 mL\n 120 mL\n TF:\n IVF:\n 484 mL\n 164 mL\n Blood products:\n Total out:\n 2,000 mL\n 800 mL\n Urine:\n 2,000 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,456 mL\n -516 mL\n Respiratory support\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n GENERAL: NAD.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema, hematoma\n or bruit\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 189 K/uL\n 13.5 g/dL\n 111 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 14 mg/dL\n 105 mEq/L\n 141 mEq/L\n 37.1 %\n 8.7 K/uL\n [image002.gif]\n 09:26 PM\n 04:23 AM\n 05:33 AM\n 04:51 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n Hct\n 41.0\n 39.7\n 39.4\n 37.1\n Plt\n 89\n Cr\n 1.1\n 0.9\n 1.2\n 1.1\n TropT\n 0.48\n 0.67\n 0.91\n Glucose\n 120\n 104\n 103\n 111\n Other labs: PT / PTT / INR:12.2/50.1/1.0, CK / CKMB /\n Troponin-T:150/9/0.91, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Persistent.\n - increased demand rate to 60 due to symptomatic bradycardia\n - d/c heparin gtt\n - check pacing wire at rounds daily to check threshold. Most recently\n 0.4.\n - appreciate EP recs\n - plan for ICD implantation in a.m.; NPO after midnight\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet; NPO after midnight for ICD implantation\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin SC; d/c heparin at 2 a.m. for pacemaker implantation\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730991, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n Heart block, complete (CHB)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730994, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for permanent pacer/ICD schedule for today,\n .\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with temp transvenous pacer, wires intact, v-paced at a\n rate of 60.\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730992, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for ICD placement today.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n" }, { "category": "Physician ", "chartdate": "2186-04-17 00:00:00.000", "description": "CCU Attending Physician Note", "row_id": 730906, "text": "TITLE: EP Follow-Up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: - Increased frequency of pacing\n - Thresold on temp wire 1.5-2 mA, set at 4.0 mA\n - no c/o, no other events\n Medications\n Unchanged\n ASA 325 mg daily\n Heparin IV SS\n Physical Exam\n General appearance: NAD, appears well lying in bed\n BP: 104 / 52 mmHg\n HR: 35 bpm\n RR: 19 insp/min\n Tmax C last 24 hours: 37.1 C\n Tmax F last 24 hours: 98.7 F\n T current C: 36.3 C\n T current F: 97.3 F\n O2 sat: 98 % on Room air\n Previous day:\n Intake: 544 mL\n Output: 2,000 mL\n Fluid balance: -1,456 mL\n Today:\n Weight: 83 kg\n Intake: 318 mL\n Output: 900 mL\n Fluid balance: -582 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND), (Auscultation: +BS)\n Extremities:\n Femoral exam: right sided temp wire with pressure dressing\n Labs\n 189\n 13.5\n 111\n 1.1\n 27\n 4.3\n 14\n 105\n 141\n 37.1\n 8.7\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n 02:23 PM\n 05:33 AM\n 05:54 PM\n 04:51 AM\n WBC\n 9.5\n 8.7\n 7.7\n 8.7\n Hgb\n 14.4\n 14.3\n 13.6\n 13.5\n Hct (Serum)\n 41.0\n 39.7\n 39.4\n 37.1\n Plt\n 89\n INR\n 1.0\n 1.0\n PTT\n 47.8\n 59.8\n 46.4\n 41.5\n 50.1\n Na+\n 137\n 140\n 141\n 141\n K + (Serum)\n 3.6\n 4.0\n 4.2\n 4.3\n Cl\n 101\n 109\n 105\n 105\n HCO3\n 25\n 22\n 27\n 27\n BUN\n 17\n 15\n 13\n 14\n Creatinine\n 1.1\n 0.9\n 1.2\n 1.1\n Glucose\n 120\n 104\n 103\n 111\n CK\n \n CK-MB\n 51\n 40\n 9\n Troponin T\n 0.48\n 0.67\n 0.91\n ABG: / / / 27 / Values as of 04:51 AM\n Tests\n Telemetry: CHB with occassional LBBB-pattern escape\n Assessment and Plan\n 43 year old M with HOCM s/p ETOH septal ablation and ASMI now c/b CHB\n with unreliable LBBB escape, utilizing temp wire with increased\n frequency overnight.\n 1. AV block: High grade\n -Continue bedrest with temp pacing required via right groin\n -Plan PPM in am (?ICD per DR. )\n -NPO at midnight, d/c heparin at 2am for procedure in am\n Will d/w Dr. and Dr. \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 S/p septal ablation now in CHB. Temporary pacer rate increased to 60\n BPM given symptoms with slower heart rate. Plan for PPM tomorrow.\n Patient care time critical care 30 minutes for management of complete\n heart block, bradycardia and temporary pacemaker.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:39 ------\n" }, { "category": "Nursing", "chartdate": "2186-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730759, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Pt admitted to CCU s/p septal ablation for HOCM w temporary wire in\n place- currently remains hemodynamically stable, awaiting permament\n pacer/ICD placement today.\n Action:\n Pt occasionally V Pacing\n sensing and pacing appropriately\n turned\n rate up to 35 to diminish 3 star alarm ringing in pt room, increasing\n his anxiety/distress. Unable to turn down alarm at bedside monitor so\n every time he paced at 30, 3 star alarm going off for 29. continue to\n closely monitor hemodynamics/BP. AM labs pending. PT NPO for planned\n ICD/pacer placement. Increased heparin gtt to 1200u for PTT<50.0.\n Response:\n Pt remains stable, free of symptoms even when pacing at 30-35. Overall\n mostly in 3\n AVB at rate in the 40\ns-50\ns. See flowsheet for VS. Pt\n free of back pain w assistance in turning, backrubs and Percocet x 1\n dose this shift. Much teaching, support, assisting in comfort and\n better sleep.\n Plan:\n Continue teaching re: pacer placement, continue comfort w assistance w\n bedrest/positioning as well as Percocet PRN as ordered. Discuss heparin\n gtt/ indications and ? d/c this AM once entire CCU team rounds. Keep pt\n aware of plan of care. c/o to 3 s/p pacer procedure today. Obtain\n consent for procedure prior to sending pt down/complete preop sheet.\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 731015, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for permanent pacer/ICD schedule for today,\n .\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with temp transvenous pacer, wires intact, no bleeding from\n right groin site. Continuously v-paced at a rate of 60. BP\n 100-110/50-60\ns. Denying any SOB, CP, dizziness. No edema noted, skin\n warm, pulses palpable throughout. Voiding adequate amounts of yellow\n urine Sp02 92-94% on RA, RR 8-12. Lungs clear. Abdomen soft with good\n bowel sounds. NPO after MN for procedure. Denying any pain.\n Action:\n Placed pt on 2 L NC at 0200 after Sp02 dropped below 90% during sleep,\n pt denied any SOB, CP, difficulty breathing. Maintained integrity of\n temp pacer. Kept pt NPO after MN, enforced bedrest. Held 0600 sc\n heparin for procedure.\n Response:\n Pt slept whole night. Continues to be v-paced at 60 BPM. Temp pacer\n wires intact, dsg intact. BP stable. UO adequate. Sp02 94-95% on 2 L NC\n during deep sleep, increases to high 90\ns when awake.\n Plan:\n Scheduled for perm pacer today, around 0930. Hemodynamic monitoring.\n Pain control (acute pain, chronic pain)\n Assessment:\n Endorsed right knee pain, when he bends it at 0500.\n Action:\n Offered pain medication but pt refused\n Response:\n Pt states pain tolerable at rest\n Plan:\n Assess pain frequently. Continue to offer pain management\n" }, { "category": "Nursing", "chartdate": "2186-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730953, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n cardiomyopathy, Hypertrophic s/p ETOH ablation c/b complete heart block\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730955, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n cardiomyopathy, Hypertrophic s/p ETOH ablation c/b complete heart block\n Assessment:\n *Pt admitted to CCU s/p septal ablation for HOCM w temporary wire in\n place- currently remains hemodynamically stable, awaiting permament\n pacer+/- ICD tomorrow.\n *Rec\nd pt w/ temp transvenous wire via R femoral vein set at VVI, rate\n 35 bpm, 100% V-paced. Site CDI w/ pressure dsg no ooze/ resolving, soft\n hematoma. Wires intact. Settings tested per EP fellow as underlying\n rhythm CHB. Ventricular stimulation threshold 2, set 4mA.\n *IV heparin gtt running\n **Pt called at while finishing breakfast. C/O dizziness/ SOB/\n palpitations. HR 47 intrinsic CHB, BP 120s/60s, SPO2 100% RA.\n Action:\n *With symptoms, pt\ns rate on temp PCM increased to 60BPM. CCU team/ EP\n fellow notified.\n *R groin site monitored/ pressure dsg removed and DSD applied.\n *Heparin gtt dc\n Response:\n *Pt immediately felt better after PCM rate increased to 60. Complete\n resolution of symptoms within 1 minute. EP came by in afternoon and\n tested PCM settings again- okay to leave rate at 60BPM.\n Plan:\n NPO after midnight to Perm PCM in AM. Pt still needs procedure consent.\n Monitor R groin PCM site.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730956, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire. Rt groin\n bleed s/p pt moving self- held pressure, pressure dsg applied.\n Small hematoma, Hct stable. Pt remains on bedrest , NPO after MN for\n permanent pacer /ICD placement.\n cardiomyopathy, Hypertrophic s/p ETOH ablation c/b complete heart block\n Assessment:\n *Pt admitted to CCU s/p septal ablation for HOCM w temporary wire in\n place- currently remains hemodynamically stable, awaiting permament\n pacer+/- ICD tomorrow.\n *Rec\nd pt w/ temp transvenous wire via R femoral vein set at VVI, rate\n 35 bpm, 100% V-paced. Site CDI w/ pressure dsg no ooze/ resolving, soft\n hematoma. Wires intact. Settings tested per EP fellow as underlying\n rhythm CHB. Ventricular stimulation threshold 2, set 4mA.\n *IV heparin gtt running\n **Pt called at while finishing breakfast. C/O dizziness/ SOB/\n palpitations. HR 47 intrinsic CHB, BP 120s/60s, SPO2 100% RA.\n Action:\n *With symptoms, pt\ns rate on temp PCM increased to 60BPM. CCU team/ EP\n fellow notified.\n *R groin site monitored/ pressure dsg removed and DSD applied.\n *Heparin gtt dc\n Response:\n *Pt immediately felt better after PCM rate increased to 60. Complete\n resolution of symptoms within 1 minute. EP came by in afternoon and\n tested PCM settings again- okay to leave rate at 60BPM.\n Plan:\n NPO after midnight to Perm PCM in AM. Pt still needs procedure consent.\n Monitor R groin PCM site.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaining of severe R knee pain directly above knee cap\n during movement, @ rest. No history of knee pain or trauma. R\n knee without warmth/ redness.\n Action:\n Given 1 percocet with no relief. Notified team- gave another Percocet\n and ice pack with no relief. CCU team notified and in to assess. Likely\n pain r/t prolonged bedrest over weekend as no obvious signs of trauma/\n gout. R leg elevated on pillow and given 800mg PO motrin. Hot pack\n applied.\n Response:\n Pt stated pain still present, but tolerable at 1900.\n Plan:\n Continue to monitor and medicate PRN.\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 731100, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for permanent pacer/ICD schedule for today,\n .\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with temp transvenous pacer, wires intact, no bleeding from\n right groin site. Continuously v-paced at a rate of 60. BP\n 100-110/50-60\ns. Denying any SOB, CP, dizziness. No edema noted, skin\n warm, pulses palpable throughout. Voiding adequate amounts of yellow\n urine Sp02 92-94% on RA, RR 8-12. Lungs clear. Abdomen soft with good\n bowel sounds. NPO after MN for procedure. Denying any pain.\n Action:\n Placed pt on 2 L NC at 0200 after Sp02 dropped below 90% during sleep,\n pt denied any SOB, CP, difficulty breathing. Maintained integrity of\n temp pacer. Kept pt NPO after MN, enforced bedrest. Held 0600 sc\n heparin for procedure.\n Response:\n Pt slept whole night. Continues to be v-paced at 60 BPM. Temp pacer\n wires intact, dsg intact. BP stable. UO adequate. Sp02 94-95% on 2 L NC\n during deep sleep, increases to high 90\ns when awake.\n Plan:\n Scheduled for perm pacer today, around 0930. Hemodynamic monitoring.\n Pain control (acute pain, chronic pain)\n Assessment:\n Endorsed right knee pain, when he bends it at 0500.\n Action:\n Offered pain medication but pt refused\n Response:\n Pt states pain tolerable at rest\n Plan:\n Assess pain frequently. Continue to offer pain management\n" }, { "category": "Nursing", "chartdate": "2186-04-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 731101, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire, v paced at\n rate of 35 until yesterday when pt started c/o dizziness and\n palpitations --- intrinsic HR 47 with CHB and subsequently rate set at\n 60 with immediate relief.\n On right groin site started bleeding after pt moving self-\n pressure dsg applied, small, soft hematoma present. Hct stable. Pt\n remains on bedrest. Waiting for permanent pacer/ICD schedule for today,\n .\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received pt with temp transvenous pacer, wires intact, no bleeding from\n right groin site. Continuously v-paced at a rate of 60. BP\n 100-110/50-60\ns. Denying any SOB, CP, dizziness. No edema noted, skin\n warm, pulses palpable throughout. Voiding adequate amounts of yellow\n urine Sp02 92-94% on RA, RR 8-12. Lungs clear. Abdomen soft with good\n bowel sounds. NPO after MN for procedure. Denying any pain.\n Action:\n Placed pt on 2 L NC at 0200 after Sp02 dropped below 90% during sleep,\n pt denied any SOB, CP, difficulty breathing. Maintained integrity of\n temp pacer. Kept pt NPO after MN, enforced bedrest. Held 0600 sc\n heparin for procedure.\n Response:\n Pt slept whole night. Continues to be v-paced at 60 BPM. Temp pacer\n wires intact, dsg intact. BP stable. UO adequate. Sp02 94-95% on 2 L NC\n during deep sleep, increases to high 90\ns when awake.\n Plan:\n Scheduled for perm pacer today, around 0930. Hemodynamic monitoring.\n Pain control (acute pain, chronic pain)\n Assessment:\n Endorsed right knee pain, when he bends it at 0500.\n Action:\n Offered pain medication but pt refused\n Response:\n Pt states pain tolerable at rest\n Plan:\n Assess pain frequently. Continue to offer pain management\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n HYPERTROPHIC CARDIOMYOPATHY ETHANOL SEPTAL ABLATION/SDA\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 81.6 kg\n Daily weight:\n 83 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: GERD, Hypercholesterolemia, Wisdom teeth\n extraction, Hypertrophic cardiomyopathy dg , mild-moderate MR\n Surgery / Procedure and date: Ethanol Ablation via R. groin.\n Introducer with temporary pacing wire in place x2 days.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:62\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 60 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 82 mL\n 24h total out:\n 650 mL\n Pacer Data\n Temporary pacemaker type:\n Transvenous\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary pacemaker wire condition:\n Attached-Pacer\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:46 AM\n Potassium:\n 5.0 mEq/L\n 04:46 AM\n Chloride:\n 104 mEq/L\n 04:46 AM\n CO2:\n 26 mEq/L\n 04:46 AM\n BUN:\n 16 mg/dL\n 04:46 AM\n Creatinine:\n 1.0 mg/dL\n 04:46 AM\n Glucose:\n 102 mg/dL\n 04:46 AM\n Hematocrit:\n 37.1 %\n 04:46 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: \n" }, { "category": "Consult", "chartdate": "2186-04-16 00:00:00.000", "description": "EP Initial Consult Note", "row_id": 730597, "text": "Consult requested by: CCU Service\n Chief Complaint: Complete Heart Block\n HPI:\n Mr. is 43 years old with hypertrophic\n cardiomyopathy. He was diagnosed 3 years ago after experiencing severe\n exertional dyspnea. Recent echocardiogram revealed asymmetric LV\n septal hypertrophy with LV septum measuring 17mm. LVOT gradient was\n inducible to 125 mm Hg. His symptoms progressed to NYHA Class III. He\n had been treated medically with disopyramide 300 mg and complained\n of anticholinergic side effects related to this treatment.\n Yesterday he underwent alcohol septal ablation with contrast\n echocardiographic guidance. Preablation LVOT gradient on 10 mg\n dobutamine measured 120 mm Hg, which subsequently decreased to 60 mm Hg\n after the procedure.\n We are asked to consult in the setting of post operative complete heart\n block.\n Patient admitted from: Home\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Other medications:\n Past medical history:\n Family history:\n Social history:\n Hypercholesterolemia\n Mild to moderate MR anterior motion of the mitral valve\n leaflet\n GERD\n No family history of hypertrophic cardiomyopathy. No history of sudden\n death.\n Father died at age 41 of suicide.\n Occupation: Sales\n Drugs: No\n Tobacco: Intermittent\n Alcohol: Social\n Other:\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Respiratory: Dyspnea\n Flowsheet Data as of 04:43 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 49 (42 - 90) bpm\n BP: 112/66(76) {82/48(58) - 131/90(98)} mmHg\n RR: 20 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm), 3rd AV (Complete Heart Block)\n Wgt (current): 813 kg (admission): 81.6 kg\n Height: 70 Inch\n Total In:\n 957 mL\n 385 mL\n PO:\n 600 mL\n TF:\n IVF:\n 357 mL\n 385 mL\n Blood products:\n Total out:\n 0 mL\n 1,600 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 957 mL\n -1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: ), Soft\n S2, Late murmur over precordium with soft apical MR murmur;\n PMI nondisplaced\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/59.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n ECG: Sinus rhythm 100 bpm with complete heart block; ventricular escape\n of 46 bpm with morphology. QRS duration of 120 ms \n of the R wave intrinsicoid in multiple leads.\n With RV pacing at 60 bpm, no retrograde VA conduction observed.\n Assessment and Plan\n Mr. is a 43 year old man with hypertrophic cardiomyopathy\n and significant exertional limitation who underwent alcohol septal\n ablation yesterday. Preprocedure ECG sinus with PR 164 and QRS 94\n ms. procedure ECG shows significant PR prolongation with RBBB and\n LAFB. Current ECG shows complete heart block with QRS duration >120\n ms morphology.\n Will continue telemetry observation with VVI pacing backup (currently\n set to VVI 30 with appropriate threshold).\n If recovery of conduction does not occur will need permanent\n pacemaker/ICD.\n MD\n EP Fellow\n ------ Protected Section ------\n Reviewed above note and Pt course to date.\n Examined Pt and agree that he has significant Conduction abnormality\n post septal ablation.\n These are unlikely to recover\n Will need Pacer-ICD pre discharge\n \n ------ Protected Section Addendum Entered By: ,MD\n on: 17:23 ------\n" }, { "category": "Nursing", "chartdate": "2186-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730598, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n This am, patient attempted to lift himself up in bed and immediately\n felt pain in R groin- R groin oozing bright red blood-> pressure held-\n CCU notified & in- pressure held until bleeding stopped, then pressure\n dsg applied- EP in- temp pacer check- pacer appropriately sensing and\n capturing.\n Action:\n Heparin gtt held X2hrs then resumed @ 1050u/hr- PTT pending- NPO after\n 12am\n Response:\n No further bleeding from R groin-\n Plan:\n Perm pacer/defib placement tomorrow.\n" }, { "category": "Physician ", "chartdate": "2186-04-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730267, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -Had 3/10 chest pain overnight. Got morphine 1 mg IV. 30 minutes later,\n nauseas, SBP decreased to 80-90s. Exam otherwise unremarkable. Pulsus\n 4. Gave Zofran 4 mg IV + NS 250 cc, with improvement in symptoms.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Morphine Sulfate - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 58 (55 - 90) bpm\n BP: 125/81(91) {82/48(58) - 128/90(98)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 957 mL\n 197 mL\n PO:\n 600 mL\n TF:\n IVF:\n 357 mL\n 197 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 957 mL\n -403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: NAD.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. II/VI crescendo-decrescendo murmur at LSB,\n augmented by clenching fists.\n LUNGS: CTAB\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema.\n PULSES:\n Right: Radial 2+ DP 2+ PT 2+\n Left: Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/47.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours\n - heparin gtt while temp wire in place (goal PTT 50)\n - check pacing wire at 10 a.m. and 10 p.m. daily to check threshold.\n Most recently 0.4.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Nursing", "chartdate": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730339, "text": "This is a 43 yr old male w/ H/O hypertrophic cardiomyopathy S/P septal\n ablation on complicated by AV block\n>S/P temp wire.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Received patient w/ venous temp wire attached/intact- pacemaker\n appropriately sensing and capturing- Tele: 1^st and 2^nd AVB noted this\n am- CHB this pm- R groin site intact- (+) palp distal pulses-\n hemodynamically stable- c/o chest pressure X2 today & SOB w/ exertion-\n good U/O.\n Action:\n Seen by EP- CXR done- Mg 1.8 mag sulfate 2gm IV given- started on\n norpace 300mg Po X1 @ 1730- heparin gtt @ 1050u/hr- emotional support\n given.\n Response:\n CCU & EP physicians spoke w/ patient re: permanent pacemaker/defib\n placement- repeat PTT @ goal 59.8\n Plan:\n Follow labs- ? need for pacer on Monday.\n" }, { "category": "Nursing", "chartdate": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730157, "text": "43 yr. old man with hypertrophic cardiomyopathy, admitted to CCU\n following ethanol ablation. He was diagnosed with HOCM in \n following symptoms of dyspnea and dizziness on exertion. His echo has\n demonstrated hypertrophic cardiomyopathy with a septum of 16mm and an\n outflow tract gradient that goes up to 125mm Hg with exertion. The\n patient has been treated with verapamil, and most recently\n disopyramide. He reports\n initial improvement with disopyramide, but since then his symptoms\n recurred. He denies any palpitations, syncope, orthopnea,or peripheral\n edema.\n .\n The patient was taken to the cardiac catheterization lab for septal\n ablation. In the cath lab, 1.5 mL of ethanol was injection into the\n first septal artery. The patient was noted to have transient complete\n heart block. A temporary pacing wire was inserted. Coronary angiography\n was normal.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730158, "text": "43 yr. old man with hypertrophic cardiomyopathy, admitted to CCU\n following ethanol ablation. He was diagnosed with HOCM in \n following symptoms of dyspnea and dizziness on exertion. His echo has\n demonstrated hypertrophic cardiomyopathy with a septum of 16mm and an\n outflow tract gradient that goes up to 125mm Hg with exertion. The\n patient has been treated with verapamil, and most recently disopyramide\n with some improvement, but recently symptoms have returned. He denies\n any palpitations, syncope, orthopnea, or peripheral edema.\n .\n The patient was taken to the cardiac catheterization lab for septal\n ablation. In the cath lab, 1.5 mL of ethanol was injection into the\n first septal artery. The patient was noted to have transient complete\n heart block. A temporary pacing wire was inserted via R. groin.\n Coronary angiography was normal.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2186-04-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 730151, "text": "TITLE: Physician Resident Admission Note\n Chief Complaint: s/p septal ablation for HOCM\n HPI: 43 yo M with hypertrophic cardiomyopathy admitted to CCU following\n septal ablation. He was diagnosed with HOCM in following\n symptoms of dyspnea and dizziness on exertion. His echo has\n demonstrated hypertrophic cardiomyopathy with a septum of 16mm and an\n outflow tract gradient that goes up to 125mm Hg with exertion. The\n patient has been treated with verapamil, and most recently\n disopyramide. He reports\n initial improvement with disopyramide, but since then his symptoms\n recurred. He denies any palpitations, syncope, orthopnea, or peripheral\n edema.\n .\n The patient was taken to the cardiac catheterization lab for septal\n ablation. In the cath lab, 1.5 mL of ethanol was injection into the\n first septal artery. The patient was noted to have transient complete\n heart block. A temporary pacing wire was inserted. Coronary angiography\n was normal.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Morphine Sulfate - 10:00 PM\n Home medications:\n Lipitor 10mg QHS\n disopyramide 300 mg \n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: none\n -PACING/ICD: none\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertrophic cardiomyopathy\n Dyslipidemia\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. No family h/o HOCM.\n Divorced, lives alone.\n -Tobacco history: Former smoker. Smoked for 5-6 years (<1 pack/day),\n then quit for 20 years. Then smoked <1 pack/day for 2-3 years (<1\n pack/day), quitting within past few months.\n -ETOH: drinks/day\n -Illicit drugs: denies\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 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.6\nC (97.8\n HR: 65 (55 - 90) bpm\n BP: 106/71(79) {101/71(78) - 128/90(98)} mmHg\n RR: 15 (10 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 957 mL\n 111 mL\n PO:\n 600 mL\n TF:\n IVF:\n 357 mL\n 111 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 957 mL\n 111 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n VS: T=98.0 BP=128/80 HR=92 RR=10 O2sat=94%/RA\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or cyanosis of\n the oral mucosa. No xanthalesma.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. No m/r/g.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Radial 2+ DP 2+ PT 2+\n Left: Carotid 2+ Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 213 K/uL\n 14.4 g/dL\n 120 mg/dL\n 1.1 mg/dL\n 17 mg/dL\n 25 mEq/L\n 101 mEq/L\n 3.6 mEq/L\n 137 mEq/L\n 41.0 %\n 9.5 K/uL\n [image002.jpg]\n \n 2:33 A3/19/ 09:26 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.5\n Hct\n 41.0\n Plt\n 213\n Cr\n 1.1\n TropT\n 0.48\n Glucose\n 120\n Other labs: CK / CKMB / Troponin-T:424/51/0.48, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n EKG: Normal sinus rhythm with 1st degree AV block. RBBB. Left anterior\n fascicular block.\n .\n 2D-ECHOCARDIOGRAM:\n .\n Echo: normal LV size with mild asymmetric septal\n hypertrophy but poriminent systolic anterior motion of mitral\n valve. 25-30mm LV outflow tract gradient, c/w diagnosis of IHSS.\n Mild left atrial enlargement with mild to moderate MR.\n stress echo: Pt exercised to stage 5 of protocol.\n No chest pain. J point elevation noted. Recovery EKG's normal.\n Echo imaging showed asymmetric septal hypertrophy with some\n systolic anterior motion of the mitral valve. Negative for\n ischemia on echo imaging. Post exercise gradient of 100 to\n 125mmHg.\n .\n ETT: none\n .\n HEMODYNAMICS: See above for right heart cath pressures\n Assessment and Plan\n ASSESSMENT AND PLAN: 43yo M with hypertrophic cardiomyopathy s/p septal\n ablation complicated by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours\n - heparin gtt while temp wire in place\n - check pacing wire at 10 a.m. and 10 p.m. daily to check threshold.\n Most recently 0.4.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Physician ", "chartdate": "2186-04-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 730224, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -Had 3/10 chest pain overnight. Got morphine 1 mg IV. 30 minutes later,\n nauseas, SBP decreased to 80-90s. Exam otherwise unremarkable. Pulsus\n 4. Gave Zofran 4 mg IV + NS 250 cc, with improvement in symptoms.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Morphine Sulfate - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 58 (55 - 90) bpm\n BP: 125/81(91) {82/48(58) - 128/90(98)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 957 mL\n 197 mL\n PO:\n 600 mL\n TF:\n IVF:\n 357 mL\n 197 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 957 mL\n -403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or cyanosis of\n the oral mucosa. No xanthalesma.\n NECK: Supple. JVP not elevated.\n CARDIAC: RRR, normal S1, S2. No m/r/g.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Transvenous pacing wire in right groin. No edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Radial 2+ DP 2+ PT 2+\n Left: Carotid 2+ Radial 2+ DP 2+ PT 2+\n Labs / Radiology\n 215 K/uL\n 14.3 g/dL\n 104 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 140 mEq/L\n 39.7 %\n 8.7 K/uL\n [image002.jpg]\n 09:26 PM\n 04:23 AM\n WBC\n 9.5\n 8.7\n Hct\n 41.0\n 39.7\n Plt\n 213\n 215\n Cr\n 1.1\n 0.9\n TropT\n 0.48\n 0.67\n Glucose\n 120\n 104\n Other labs: PT / PTT / INR:/47.8/, CK / CKMB / Troponin-T:325/40/0.67,\n Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 43yo M with hypertrophic cardiomyopathy s/p septal ablation complicated\n by transient AV block s/p temporary pacing wire.\n .\n # Hypertrophic cardiomyopathy s/p septal ablation:\n - holding disopyramide for now; discuss when to restart with Dr. \n - bedrest while sheath in place\n - trend cardiac enzymes; serial EKGs\n - ASA 325 mg daily\n .\n # Complete Heart Block: Complication of septal ablation. Resolved.\n - temp pacing wire in place for 48 hours\n - heparin gtt while temp wire in place\n - check pacing wire at 10 a.m. and 10 p.m. daily to check threshold.\n Most recently 0.4.\n - serial EKGs\n .\n # Dyslipidemia:\n - continue Lipitor\n .\n # EtOH use:\n - will monitor with CIWA\n - diazepam 5mg Q6H prn CIWA > 10\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:00 PM\n 18 Gauge - 07:04 PM\n Prophylaxis:\n DVT: heparin IV as above\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with patient\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Nursing", "chartdate": "2186-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 730217, "text": "43 yr. old man with hypertrophic cardiomyopathy, admitted to CCU\n following ethanol ablation. He was diagnosed with HOCM in \n following symptoms of dyspnea and dizziness on exertion. His echo has\n demonstrated hypertrophic cardiomyopathy with a septum of 16mm and an\n outflow tract gradient that goes up to 125mm Hg with exertion. The\n patient has been treated with verapamil, and most recently disopyramide\n with some improvement, but recently symptoms have returned. He denies\n any palpitations, syncope, orthopnea, or peripheral edema.\n .\n The patient was taken to the cardiac catheterization lab for septal\n ablation. In the cath lab, 1.5 mL of ethanol was injection into the\n first septal artery. The patient was noted to have transient complete\n heart block. A temporary pacing wire was inserted via R. groin.\n Coronary angiography was normal.\n .H/O cardiomyopathy, Hypertrophic\n Assessment:\n Afeb. WBC 9.5.\n HR 59-90 SB/SR with occ. PVC. ! episode HR 35-40. No pacing. Resolved\n quickly.\n BP 101-128/71-90.\n O2 sat 94-96% on Rm Air. BS clear.\n Temp pacing wire via R groin introducer. Set at VD 30.\n R. groin site C&D. +BPPP.\n ~2200 C/O CP .\n K 3.6, Mg 2.0, CK 424 with MB 51, Trop 0.48\n Action:\n Morphine 1mg VP for CP\n Heparin gtt started @ 900units/hr @ 2145.\n KCL 20meq PB x2 for low K.\n Response:\n Relief of CP with morphine, but ~2230 C/O nausea, dry mouth, &\nreally\n not feeling well\n SBP 84-95.\n Zofran 4mg VP with good effect. NS 250cc bolus given x1. SBP>100.\n PTT 47.8. Heparin gtt increased to 1050units/hr.\n Repeat K 4.0.\n Plan:\n Will need temp pacing wire to stay in place x2 days.\n Repeat PTT ~1300.\n Serial CK\ns until trending down.\n" }, { "category": "ECG", "chartdate": "2186-04-19 00:00:00.000", "description": "Report", "row_id": 229605, "text": "Sinus rhythm. Atrial sensed and ventricular paced rhythm with capture, new as\ncompared with prior tracing of .\n\n" }, { "category": "ECG", "chartdate": "2186-04-16 00:00:00.000", "description": "Report", "row_id": 229606, "text": "Sinus rhythm. A-V dissociation is suggested. Compared to the previous tracing\ncomplete heart block is now suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2186-04-15 00:00:00.000", "description": "Report", "row_id": 229848, "text": "Sinus rhythm. Right bundle-branch block. Left anterior fascicular block.\nCompared to the previous tracing there is no change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2186-04-14 00:00:00.000", "description": "Report", "row_id": 229849, "text": "Sinus bradycardia. Prolonged P-R interval. Right bundle-branch block with left\nanterior fascicular block. Compared to the previous tracing trifascicular block\nis now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-04-14 00:00:00.000", "description": "Report", "row_id": 229850, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2186-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126621, "text": " 4:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary process/interval change\n Admitting Diagnosis: HYPERTROPHIC CARDIOMYOPATHY\\ETHANOL SEPTAL ABLATION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 y.o male with hx of HOCM s/p septal ablation now with dyspnea with minimal\n exertion\n REASON FOR THIS EXAMINATION:\n ? pulmonary process/interval change\n ______________________________________________________________________________\n WET READ: RSRc SAT 11:07 PM\n No evidence of acute process. Unclear tubular structure ? outside patient vs.\n vascular catheter in IVC/RA. 11p .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of septal ablation, dyspnea, evaluation for pulmonary\n process.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: Questionable inferior vena cava catheter with the tip looping in\n the right atrium.\n\n Otherwise unremarkable chest radiograph. Normal size of the cardiac\n silhouette. No pulmonary edema. No pleural effusion. No pneumonia or\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126687, "text": " 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for change in position of temporary pacing wire.\n Admitting Diagnosis: HYPERTROPHIC CARDIOMYOPATHY\\ETHANOL SEPTAL ABLATION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with temporary venous pacing wire in place. Moved in bed\n abruptly this morning, now with pain at right groin ?movement of pacing wire at\n right groin.\n REASON FOR THIS EXAMINATION:\n Assess for change in position of temporary pacing wire.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Temporary pacing wire. Assessment for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n slightly decreased, likely to reflect a lesser inspiratory effort. The\n position of the pacing line is unchanged. Borderline size of the cardiac\n silhouette without evidence of pulmonary edema. No pleural effusions, no\n focal parenchymal opacities suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-04-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1127177, "text": " 9:39 AM\n CHEST (PA & LAT) Clip # \n Reason: lead position\n Admitting Diagnosis: HYPERTROPHIC CARDIOMYOPATHY\\ETHANOL SEPTAL ABLATION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man s/p ICD\n REASON FOR THIS EXAMINATION:\n lead position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old male with ICD placement.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: A left chest wall pacemaker/AICD device is in place,\n with leads overlying the right atrium and ventricle. There is no mediastinal\n widening, pneumothorax, or pleural effusion. The lungs are clear. The\n cardiomediastinal silhouette and hilar contours are normal.\n\n IMPRESSION: ICD placement, without complications.\n\n" } ]

[ { "category": "ECG", "chartdate": "2112-07-08 00:00:00.000", "description": "Report", "row_id": 276667, "text": "Atrial fibrillation, average ventricular rate 116. Right bundle-branch block.\nDiffuse non-diagnostic repolarization abnormalities. Compared to the previous\ntracing of the ventricular rate is significantly increased. Otherwise,\nno major change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2112-07-14 00:00:00.000", "description": "Report", "row_id": 276663, "text": "Atrial fibrillation with controlled ventricular response. Right bundle-branch\nblock. Compared to the previous tracing of there is no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2112-07-10 00:00:00.000", "description": "Report", "row_id": 276664, "text": "Atrial fibrillation, average ventricular rate 62. Compared to the previous\ntracing there is no diagnostic change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2112-07-09 00:00:00.000", "description": "Report", "row_id": 276665, "text": "Atrial fibrillation, average ventricular rate 95. Compared to the previous\ntracing the ventricular rate is reduced. Otherwise, no diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2112-07-08 00:00:00.000", "description": "Report", "row_id": 276666, "text": "Atrial fibrillation, average ventricular rate 119. Compared to the previous\ntracing multiple abnormalities as previously reported persist without major\nchange.\nTRACING #2\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1319767, "text": "resp care\npt was extubated on rounds with sicu team present. tolerated very well and presently weaned to nasal cannula in nard.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1319768, "text": "Nursing Progress Note:\nPlease refer to CareVue and transfer note for details.\n Pt A&Ox3. Follows commands and MAE. PERRLA. VSS. Afebrile. CCO PA line d/c'd by Dr. and changed over wire to a triple lumen central line. Labs q8hr. A-line d/c'd at 1900. Pt w/ generalized anasarca. Furosemide 20mg IV TID ordered. Lungs coarse at times; clear after coughing. Pt extubated this AM. Pt w/ strong cough. Pt using incentive spirometer q30min-1hr. Expectorated moderate amount thick, white secretions; pt using Yankauer approp. O2 sat >/= 96% on 4LNC. Pt c/o incisional pain when coughing; cough pillow given and pt stated that it helps relieve pain. Morphine 2mg IV x4 given w/ +effect. Abomen softly distended w/ hypoactive BS. NPO. NGT to LCS w/ moderate amount bilious drainage. No c/o nausea. No BM this shift. Insulin gtt on most of shift, but d/c'd at 1700. BS checked q1hr when on insulin gtt. Foley w/ clear, amber urine. UO qs. Abdominal incision w/ staples . Moderate amount of serosang drainage; DSD changed x3. JPx2 to bulb suction w/ small amount serosang drainage; emptied q2hr. Pt OOB to chair w/ 1assist. Transferred to 10 w/ transport personnel at . sister, niece, nephew aware of transfer. Continue to monitor VS, I's and O's, labs. Update pt and family w/ plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1319762, "text": "resp care note\n\nPt is PO liver transplant arriving in sicu A ~ 0600. SHe has tight wheezes bilat but aeration is noticible better on R than L. She is intubated wth # 8 ETT @ 23 lip. Pips are ~ 35 cm with Vt 480, I time 1.1, ramp 30%. ETT may be too deep, CXR being done. Pt has hx smoking. Sx for scant amt thk wht. First ABG in unit .42,44,199. FiO2 decreased to 50%. Noted that Pco2 is higher than in OR although pH is nl, may need to adjust as she warms but ETT may need to be pulled back.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1319763, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS. PT ADMITTED FROM OR AT 0600- S/P OLTX. ON SM DOSES OF NEO DURING CASE- OFF ON ADMISSION.\nNEURO: SEDATED ON LOW DOSE PROPOFOL GTT UNTIL 1400. PT FOLLOWING COMMANDS OFF GTT. MAE ON BED, ATTEMPTS TO LIFT AND HOLD ALL EXTREMITIES. NODS YES/NO. ATTEMPTING TO MOUTH WORDS. MEDICATED WITH MS 2MG IV X3 FOR PAIN WITH GOOD RELIEF\nCV: T MAX 99.5. HR 108- 96 ST TO NSR. SBP 120-145. CVP 22 TO 14 (AFTER LASIX). CO 11 TO 8.\nHEME: TRANSFUSED WITH 1 UNIT PC FOR HCT 28.4. REPEAT HCT 32.2 TO 34.8. PLT COUNT 62-59 (NOT TX PER PATHWAY)\nRESP: BS DIMINSHED ON LEFT ON ADMISSION. CXR SHOWED ETT IN RIGHT MAIN STEM BRONCHUS. PULLED BACK 3-4CM. REPEAT CXR DONE. BRONCHOSCOPY DONE- SX FOR MOD AMT THICK WHITE-YELLOW SECRETIONS. PT CHANGED TO CPAP THIS AFTERNOON IN ATTEMPT TO EXTUBATE. ABG POOR, IPS INCREASED TO 10.\nGI: NPO, ABD SOFTLY DISTENDED WITH ABSENT BS. NGT PATENT AND DRAINING COLORED FLUID.\nGU: PT GIVEN LASIX 20MG IV X2 WITH GOOD DIURESIS.\nWOUND: ABD INCISION CLEAN, STAPLES INTACT. DRESSING CHANGED X1 FOR MOD AMT SEROSANG DRAINAGE. 2 JP'S TO BULB SX DRAINING SM AMTS SEROSANG. ABD USN DONE THIS AM\nP: CONT. TO MONITOR HEMODYNAMICS CLOSELY, LABS Q8HRS PER PATHWAY, RESTART PROPOFOL AS NEEDED WITH GOAL OF D/'CING IN EARLY AM AND POSSIBLE EXTUBATION, CXR PRIOR TO EXTUBATION PER DR \n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1319764, "text": "Respiratory Care\nPt ETT pulled back to 18cm. Pt bronched for diminished BS on L side. Recruitment Manuvers done to improve L side lung expansion. Pt weaned to CPAP.\nPlan: Maintain current settings, wean to extubate tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1319765, "text": "CONDITION UPDATE\nVSS. LOWGRADE TEMP. PT SEDATED ON PPF - AROUSEABLE TO VOICE. ABLE TO FOLLOWING SIMPLE COMMANDS. MAE W/ EQUAL STRENGTH. PUPILS EQUAL AND BRISKLY REACTIVE. REMAINS ON CPAP W/ PSUPP OF 10 - ABG ACCEPTABLE ON THIS SETTING. OCC SUCTIONING FOR THICK YELLOW SECRETIONS. LUNGS COARSE TO DIMINISHED AT BASES. ABD SOFTLY DISTENDED. SURGICAL DRS . JP'S TO BULB SUCTION. MOD AMT S/S DRAINAGE OUT. NO BOWEL SOUNDS AUSCULTATED. NGT TO LWCS. BILIOUS DRAINAGE OUT. REMAINS NPO. INSULIN DRIP FOR DIABETIC MANAGEMENT. SEE FLOWSHEETS FOR SPECIFICS. U/O QS VIA FOLEY. NO STOOL THIS SHIFT.\nCONT STRICT I/O MONITOR. WEAN FROM VENT AS TOLERATES, PLAN FOR EXTUBATION IN AM IF APPROPRIATE. PAIN MANAGEMENT. MONITOR FOR S/S OF INFECTION/REJECTION. CONT TXPLANT PROTOCOL. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1319766, "text": "RESP CARE NOTE\n\n Pt is SP for liver transplant secondry to Hep A contracted from shell fish in . SHE HAS SMOKING HX. Currently she is on PSV 5/+5, 50%. There is small to mod amt of thck wht - pale yellow. Pt is very awake/alert and plan is to extubate this A.M. RSBI is ~ 20-39\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1319761, "text": "Sicu Admit Note\nPlease see carvue for specifics:\nPt arrived S/P liver tx at 0600 with anesthesia. Pt arrived not reversed and placed on prop gtt. Pt arrived with CCO PA line trauma line, Ric line and Aline intact. Pt stable throughout case per anesthesia. Currently awaiting CXR to confirm placement of ETT, breathe sounds diminished on left side and pt with wheezes throughout. VS stable and PA numbers reflecting hyperdynamic status. Labs sent EKG done. Cont to follow pathway as indicated.\n" }, { "category": "ECG", "chartdate": "2172-06-16 00:00:00.000", "description": "Report", "row_id": 201088, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing, T wave changes resolved\n\n" }, { "category": "ECG", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 201089, "text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nSeptal and lateral ST-T changes are nonspecific\nSince previous tracing, QRS changes in lead V3 - ? lead placement and T wave\nchanges noted\n\n" }, { "category": "Radiology", "chartdate": "2172-06-17 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 917852, "text": " 11:06 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: liver transplant overnight. evaluate liver and vessels\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with autoimmune hepatitis with worsening liver failure.\n\n REASON FOR THIS EXAMINATION:\n liver transplant overnight. evaluate liver and vessels\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post liver transplant one day prior.\n\n FINDINGS: Both -scale and color Doppler ultrasound examination of the\n liver was performed. There is a small amount of fluid in the region of the\n porta hepatis. The main portal vein is patent and its flow is hepatopetal.\n Appropriate flow and directionality is identified in the main portal vein,\n left portal vein and posterior right portal vein. The anterior right portal\n vein could not be visualized.\n\n The left, middle and right hepatic veins are patent with normal waveforms. The\n main hepatic artery and left hepatic arteries are patent with normal\n waveforms. The right hepatic artery is not visualized.\n\n IMPRESSION: Right hepatic artery and anterior right portal vein not\n visualized on today's examination due to technically difficult access.\n Otherwise, unremarkable study.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 918015, "text": " 10:23 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: R SCL change over a wire, check position\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLT\n REASON FOR THIS EXAMINATION:\n R SCL change over a wire, check position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Change of right subclavian line over a wire.\n\n Portable AP chest radiograph compared to the previous film done the same day\n earlier at 04:53 a.m.\n\n The right internal jugular line tip now is 3 cm below the cavoatrial junction.\n There is no pneumothorax.\n\n The heart size is enlarged but stable. There is an additional improvement in\n the left lower lobe atelectasis but now there is a new right lower lobe\n consolidation which could also represent atelectasis but infectious process\n cannot be excluded. The right pleural effusion is small. There is no sizable\n left pleural effusion. There is no evidence of pulmonary edema on the current\n x-ray.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 917823, "text": " 8:09 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: adjustment of ETT\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLT\n\n REASON FOR THIS EXAMINATION:\n adjustment of ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant and adjustment of endotracheal tube.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: Since the previous examination, the endotracheal tube has been\n repositioned and now terminates 2.5 cm from the carina. Right internal\n jugular venous access sheath with pulmonary artery catheter terminating in\n main pulmonary artery. Nasogastric tube in unchanged position with tip below\n the borders of the radiograph. The degree of left lung atelectasis has\n progressed in the interval, with continued leftward mediastinal shift.\n Minimal opacity at the right apex appears somewhat improved. Two peritoneal\n drains in unchanged position.\n\n IMPRESSION: Status post repositioning of endotracheal tube with tip now in\n standard position. Left lung atelectasis has progressed. Improvement in\n right apical opacity, possibly representing improving aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 917975, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ready to extubate w/ lung expansion\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLT with prior L lung down,now improved\n\n REASON FOR THIS EXAMINATION:\n ? ready to extubate w/ lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the left lung expansion.\n\n Portable AP chest radiograph compared to .\n\n The ET tube, the Swan-Ganz tip, and the NG tube are in standard position as\n well as two right abdominal drains.\n\n The left lower lobe consolidation has been markedly improved. The right\n pleural effusion is new. There is mild engorgement of pulmonary vasculature\n representing mild pulmonary edema.\n\n The mild cardiomegaly is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 917811, "text": " 6:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess lines, ETT\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLT\n REASON FOR THIS EXAMINATION:\n assess lines, ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, assess lines and endotracheal tube.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube terminates in the right mainstem bronchus.\n Right internal jugular venous access catheter with PA catheter tip in main\n pulmonary artery. Nasogastric tube terminates below the diaphragm with tip\n below the borders of the radiograph. There is volume loss and opacity within\n the left lung consistent with atelectasis. Minimal patchy opacity at the\n right lung apex could represent aspiration. No pneumothorax. Two peritoneal\n drains in place, and metallic skin staples seen overlying the upper abdomen.\n\n IMPRESSION:\n 1. Right mainstem bronchus intubation with left lung atelectasis. At the\n time of this dictation, the tube has been repositioned.\n 2. Patchy right apical aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-16 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 917767, "text": " 5:51 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: LIVER FAILURE\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with ESLD from autoimmune hepatitis, with elev WBC count,\n recent episode of somnolence\n REASON FOR THIS EXAMINATION:\n pre op liver transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old female with end-stage liver disease from autoimmune\n hepatitis with elevated white blood cell count and recent episode of\n somnolence. Pre-op for liver transplant. Surgery planned .\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPHS:\n\n The heart size is normal. Mediastinal and hilar contours are grossly\n unremarkable. There is slight prominence of the pulmonary vasculature, with\n mild cephalization, within normal limits. No evidence of interstitial or\n airspace markings. No pleural effusions. Surrounding osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION:\n\n No actute cardiopulmonary processes.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 918039, "text": " 1:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: line moved back\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLT\n\n REASON FOR THIS EXAMINATION:\n line moved back\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: at 10:19 a.m.\n\n INDICATION: Line repositioning.\n\n A right internal jugular vascular catheter has been withdrawn several\n centimeters, now terminating in the lower superior vena cava. There is no\n pneumothorax. There has been improvement in degree of bibasilar atelectasis\n with only minimal residual discoid atelectasis remaining. There is otherwise\n no change from the recent study of several hours earlier the same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 917847, "text": " 10:50 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: post bronch for left lung collaps. evaluation of lung field\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLT\n\n REASON FOR THIS EXAMINATION:\n post bronch for left lung collaps. evaluation of lung field reexpansion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:09 A.M., \n\n HISTORY: Liver transplant.\n\n IMPRESSION: AP chest compared to 6:34 a.m. and 8:20 a.m. today:\n\n Left upper lobe has reexpanded. Left lower lobe collapse is improved. Edema\n has cleared from the right lung. Mild cardiomegaly unchanged. ET tube,\n Swan-Ganz catheter and nasogastric tube in standard placements. Right upper\n abdominal drain unchanged. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-18 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 918008, "text": " 9:49 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: assess vascular flow\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with autoimmune hepatitis with worsening liver failure\n s/p OLT yesterday AM, unable to establish adequate views on yesterday's U/S\n\n REASON FOR THIS EXAMINATION:\n assess vascular flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old female with autoimmune hepatitis and worsening liver\n failure, status post orthotopic liver transplant on . Please obtain\n additional views of right hepatic artery and anterior right portal vein.\n\n LIMITED LIVER DOPPLER EXAMINATION: Targeted additional views of the right\n anterior and posterior portal veins demonstrated wall-to-wall color flow and\n velocity measuring 31 cm/sec. The right hepatic artery was widely patent with\n good upstrake and a resistive index of 0.60.\n\n IMPRESSION: Patent right anterior and posterior portal veins, and right\n hepatic artery with normal direction of flow and waveforms.\n\n Findings called to Dr. at 1:00 p.m. on .\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2189-11-25 00:00:00.000", "description": "Report", "row_id": 1606397, "text": "ADMITING NOTE\nNEURO: ALERT AND ORIENTED X3 ABLE TO MAE ON COMMAND C/ EQUAL STRENGTH. PERL. HA MEDICATED C/ MSO4 C/ GOOD RESULT. DENIES DOUBLE VISION. CRANIAL NERVES INTACT.INCISION DRESSED, CLEAN AND INTACT.\n\nCV: NIPPRIDE STOPPED AS PT ARRIVED ON N-SICU. LATER SLIGHTLY ABOVE RANGE MEDICATED X1 C/ HYDRALAZINE. C/ GOOD RESULTS SBP TO BE KEPT BELOW 140--NSR. NS C/ 20 K MAINT FLUID. CAP REFILL WNL AT 2 SEC. PULSES EASILY PALPABLE. A-LINE PATENT.\n\nRESP: PT HAS A TRACHEOSTOMY DUE TO DIFFICULT INTUBATION FOR STENOSIS OF TRACHEA. SATS 100% REGULAR BREATHING LUNG SOUNDS CLEAR ON TOP DAMINISHED AT BOTTOM.\n\nGI/GU: FOLEY CATH PATENT AND DRAINING LIGHT YELLOW CLEAR URINE--PASSING FLATTUS AND POSITIVE BOWEL SOUNDS.\n\nSOCIAL: FAMILY VISIT. MOTHER IN TO SEE HIM.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1606398, "text": "NEURO STATUS INTACT; GOOD BP CONTROL NO NEED FOR NIPRIDE; 2 EPISODES OF INCREASED NAUSEA/VOMITTING MED WITH EFFECT.\nTRACH #4SHILEY PATENT;C+DB INDEPENDANTLY\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1606399, "text": "Respiratory Care:\n\nPatient trached with 4.0 cuffed shiley trach. Pt. comfortable wearing 40% trach mask. 02 sats 100%. RR 14-18. Sx'd not indicated at this time. Ambu bag and spare trach at bedside. No further changes made. Wean Fio2 as tolerated. Will follow for Q shift trach checks.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1606400, "text": "Respiratory Care\nRespiratory seeing pt Q shift for trache check. Pt has #4 shiley, currently on 40% TM, 02 sat 100%. Breath sounds are clear, no sx needed at this time. Pt has spare trache and ambu at bedside. Respiratory will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1606401, "text": "nsg transfer note\n51 yo male s/p frontal craniotomy 2nd to astrocytoma. psh crani with irridation, crani- 33 fractions placed, trach done 2nd to difficult airway/difficult intubation. pmh: radiation therapy, diabetes 2nd decadron, smoker,gerd. pt is A+O, peerl,moves all ext wnl, tol up to chair minimal assist. trach #4-cuff down able to cough own secretions. can advance diet as tol post mri. piv x2, foley to gravity to be dc post mri. allergic to pcn and silk tape.\n" }, { "category": "ECG", "chartdate": "2189-11-20 00:00:00.000", "description": "Report", "row_id": 150740, "text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nof the rate is faster, otherwise there is no change.\n\n" }, { "category": "ECG", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 150973, "text": "Sinus rhythm. Non-specific ST-T wave flattening in leads I, aVL, V5-V6. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 749293, "text": " 4:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with brain cancer s/p trach\n REASON FOR THIS EXAMINATION:\n s/p trach r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH:\n\n HISTORY: Status post tracheostomy, rule out pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: A new endotracheal tube is identified and is well positioned within\n the trachea. There is no pneumothorax. The cardiac silhouette is not\n enlarged. The mediastinal contour is unremarkable. There are no focal\n pulmonary opacifications. The left costophrenic angle appears blunted which\n may be secondary to overlying soft tissue, however small left sided pleural\n effusion cannot be ruled out. No osseous abnormalities are identified.\n\n IMPRESSION: Well positioned endotracheal tube and no evidence of\n pneumothorax. Possible small left sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-26 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 749693, "text": " 12:54 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: post op check of tumor s/p resection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n post op check of tumor s/p resection\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post resection of tumor.\n\n COMPARISON: \n\n NOTE: The patient had difficulty with the examination due to persistent cough\n and trouble breathing through tracheostomy, and also had pain in head and\n neck.\n\n TECHNIQUE: Multiplanar T1 and T2W images of the head with and without IV\n contrast.\n\n MR HEAD WITH AND WITHOUT IV CONTRAST: There is a large right frontal lobe\n lesion which involves a portion of the corpus callosum, not increased in size.\n The lesion has T1 rim hyperintensity and has mixed high and low T2 signal and\n also susceptibility artifact, most compatible with hemorrhage of different age\n post resection. There is surrounding edema in the right frontal lobe. The\n lesion has slight persistent enhancement posteriorly and inferiorly, likely\n representing residual tumor. In addition there is an enhancing lesion at the\n anterior right temporal lobe measuring approximately 14 mm, which has\n surrounding edema, worsened from . There is a small right frontal\n subdural hematoma, and also left subgaleal and scalp hematomas related to\n recent surgery. The visualized paranasal sinuses are clear.\n\n IMPRESSION: 1) Post resection of large right frontal lobe lesion.\n 2) Slight persistent enhancement posteriorly and inferiorly to resection bed,\n likely residual tumor. 3) Enhancing lesion with surrounding edema at right\n anterior temporal lobe, worsened from .\n\n" } ]

[ { "category": "ECG", "chartdate": "2200-02-07 00:00:00.000", "description": "Report", "row_id": 127055, "text": "Sinus rhythm and occasional ventricular ectopy. A-V conduction delay. Compared\nto the previous tracing of there is no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2200-02-07 00:00:00.000", "description": "Report", "row_id": 127056, "text": "Sinus rhythm with a single ventricular premature beat. Since the previous\ntracing the ventricular premature beats are less frequent. Otherwise,\nunchanged.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2200-02-06 00:00:00.000", "description": "Report", "row_id": 127057, "text": "Sinus rhythm with ventricular premature beats. Consider left atrial\nabnormality. Left axis deviation. Since the previous tracing of \nthe ventricular premature beats are new. The axis is more leftward.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402144, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Received pt in angio. Pt alert and oriented x3. No c/o pain.\n Intermittent nausea and positive emesis of approximately 120cc of\n green bilious emesis prior transger back to SICU post angio\n s/p in angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses weak/marked and Doppler used post angio\n protocol. Bedrest w/ right leg straight until 0200\n Total of 4uFFP given by RN.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Tele SR w/ high frequency of PVCs. SBP >100\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units.\n HCT post 2uPRBC 24.5 (20.1). Serial HCTs Q4hrs\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n" }, { "category": "Nursing", "chartdate": "2200-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402282, "text": "asssement:\n alert and oriented x3\n breath sounds clear\n abdomen firm with + bowel sounds\n angio site clean and dry, palpable pulses\n ivf at 75cc/hr\n Action:\n hemodynamics monitored\n serial HCT and INR q6hrs\n oob to chair for 4 hrs\n medicated with Dilaudid for abdominal pain and pain in left leg\n (arthritits)\n Response:\n HCT and INR stable\n Plan:\n continue q6hr HCT and INR draws\n monitor hemodynamics\n advance diet to clears as tolerated\n increase activity as tolerate\n ?transfer to floor tomorrow\n :\n" }, { "category": "Nursing", "chartdate": "2200-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402272, "text": "asssement:\n alert and oriented x3\n breath sounds clear\n abdomen firm with + bowel sounds\n angio site clean and dry, palpable pulses\n ivf at 75cc/hr\n Action:\n hemodynamics monitored\n serial HCT and INR q6hrs\n oob to chair for 4 hrs\n medicated with Dilaudid for abdominal pain and pain in left leg\n (arthritits)\n Response:\n HCT and INR stable\n Plan:\n continue q6hr HCT and INR draws\n monitor hemodynamics\n advance diet to clears as tolerated\n increase activity as tolerate\n ?transfer to floor tomorrow\n" }, { "category": "Nursing", "chartdate": "2200-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402273, "text": "asssement:\n alert and oriented x3\n breath sounds clear\n abdomen firm with + bowel sounds\n angio site clean and dry, palpable pulses\n ivf at 75cc/hr\n Action:\n hemodynamics monitored\n serial HCT and INR q6hrs\n oob to chair for 4 hrs\n medicated with Dilaudid for abdominal pain and pain in left leg\n (arthritits)\n Response:\n HCT and INR stable\n Plan:\n continue q6hr HCT and INR draws\n monitor hemodynamics\n advance diet to clears as tolerated\n increase activity as tolerate\n ?transfer to floor tomorrow\n :\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n .\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n" }, { "category": "Physician ", "chartdate": "2200-02-11 00:00:00.000", "description": "Intensivist Note", "row_id": 402335, "text": "SICU\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further management\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Current medications:\n Vitamin D, Lipitor 80 mg PO Daily, Fiorinal Prn headache, Aspirin 81 mg\n PO Daily, Lisinopril 20 mg PO Daily, Clindamycin for dental work,\n Metoprolol 50 mg PO BID, Synthroid 125 mcg PO Daily and 250 mch\n Wednesday and Sunday, Coumadin 5 mg PO Daily\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:54 AM\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 10:00 AM\n Other medications:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 82 (76 - 92) bpm\n BP: 123/59(73) {97/47(64) - 146/76(80)} mmHg\n RR: 19 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 92.4 kg (admission): 91.3 kg\n CVP: 0 (0 - 13) mmHg\n Total In:\n 2,205 mL\n 586 mL\n PO:\n 150 mL\n 80 mL\n Tube feeding:\n IV Fluid:\n 2,055 mL\n 506 mL\n Blood products:\n Total out:\n 1,449 mL\n 130 mL\n Urine:\n 1,449 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 756 mL\n 456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 307 K/uL\n 9.5 g/dL\n 85 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.4 %\n 10.4 K/uL\n [image002.jpg]\n 02:19 AM\n 05:54 AM\n 12:21 PM\n 06:35 PM\n 12:00 AM\n 03:01 AM\n 09:52 AM\n 04:27 PM\n 10:41 PM\n 03:47 AM\n WBC\n 14.9\n 10.5\n 10.4\n Hct\n 24.7\n 22.6\n 26.2\n 26.6\n 25.5\n 26.1\n 28.7\n 27.1\n 27.6\n 28.4\n Plt\n 188\n 218\n 307\n Creatinine\n 0.7\n 0.6\n 0.6\n Glucose\n 128\n 90\n 85\n Other labs: PT / PTT / INR:12.9/23.4/1.1, Ca:9.0 mg/dL, Mg:1.9 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70F discharged after gastroenteritis on lovenox\n and coumadin with large rectus sheath hematoma\n Neurologic: -- AOX3\n -- pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular: -- CABG, MV mechanical on coumadin, held\n currently\n -- reverse INR to < 2 with FFP\n -- HD stable\n -- Given risk of thrombus from mechanical valve, and stable HCT\n cardiology feels that it is best to restart anticoagulation with\n heparin drip, and if stable over 48 hours or so, restart coumadin.\n After discussing w/ primary team, plan to restart heparin drip in\n AM.\n Pulmonary: -- sat'ing well on RA\n Gastrointestinal / Abdomen: -- rectus abominus sheath hematoma. Went to\n IR , unable to be embolized secondary to totuous vessels. Of note,\n no active bleeding seen during the procedure.\n -- zofran prn n/v\n -- bowel regimen: senna, colace\n -- GI prophy: famotidine\n Nutrition: clears\n Renal: monitor stable UOP\n Hematology: -- HCT and INR stable . If plan to restart heparin\n today, continue to check HCT q 8 hrs.\n -- : vit K 2mg IV, 5 unit FFP, 2u PRBC\n -- : 1u PRBC HCt: 26.2-->26--> 25.5 (stable), INR 1.1\n -- goal INR < 2 until bleed resolved\n Endocrine: --cont levothyroxine,\n -- RISS\n Infectious Disease: no issues, afebrile\n Lines / Tubes / Drains: PIV x1, RIJ CVL\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery, Cardiology, IR\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:06 PM\n Multi Lumen - 04:51 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402332, "text": " Problem - Description In Comments\n Assessment:\n Pt A&O x 3. PERRL. Pt c/o LLE pain. Pt remains on Q 6 hour hct\n and INR checks. Pt hemodynamically stable throughout shift.\n Occasional PVC\ns noted during shift. Team aware.\n Action:\n Given 5mg Oxycodone at 2300. Lytes replaced.\n Response:\n Pt slept throughout night. No further c/o pain or discomfort. 0400\n hct 28.4, INR 1.1\n Plan:\n ? call out\n con\nt Q 6 hour INR and hct checks. Monitor for pain.\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402159, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Received pt in angio. Pt alert and oriented x3. No c/o pain.\n Intermittent nausea and positive emesis of approximately 120cc of\n green bilious emesis prior transger back to SICU post angio\n s/p in angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses palpable but weak/marked and Doppler used\n post angio protocol. Bedrest w/ right leg straight until 0200\n Total of 4uFFP given by RN.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Bilateral labia w/ bruising\n Tele in 1^st degree AV block. PR >.2. Frequenct PVCs. SBP\n >90\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units.\n HCT post 2uPRBC 24.5 (20.1). Serial HCTs Q4hrs\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Right groin benign. Pulses noted\n No further c/o nausea. Abd remains tender to palp. No\n request for PRN pain med\n HCT stable at 24.7. K 3.4\n 40meq IV KCL admin\n Tele remains in 1^st degree AV block. PVC frequency less\n since repletion of lytes.\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402155, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Received pt in angio. Pt alert and oriented x3. No c/o pain.\n Intermittent nausea and positive emesis of approximately 120cc of\n green bilious emesis prior transger back to SICU post angio\n s/p in angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses palpable but weak/marked and Doppler used\n post angio protocol. Bedrest w/ right leg straight until 0200\n Total of 4uFFP given by RN.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Bilateral labia w/ bruising\n Tele in 1^st degree AV block. PR >.2. Frequenct PVCs. SBP\n >100\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units.\n HCT post 2uPRBC 24.5 (20.1). Serial HCTs Q4hrs\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Right groin benign. Pulses noted\n No further c/o nausea. Abd remains tender to palp. No\n request for PRN pain med\n HCT stable at 24.7. K 3.4\n 40meq IV KCL admin\n Tele remains in 1^st degree AV block. PVC frequency less\n since repletion of lytes.\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n" }, { "category": "Physician ", "chartdate": "2200-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 402221, "text": "SICU\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n .\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Current medications:\n 1. 2. 3. 1000 mL LR 4. Acetaminophen 5. Calcium Gluconate 6. Dextrose\n 50% 7. Docusate Sodium 8. Famotidine 9. Furosemide 10. Glucagon 11.\n HYDROmorphone (Dilaudid) 12. 13. 14. Insulin 15. Levothyroxine Sodium\n 16. Magnesium Sulfate 17. Ondansetron 18. OxycoDONE (Immediate Release)\n 19. Pneumococcal Vac Polyvalent 20. Potassium Chloride 21. Potassium\n Phosphate 22. Senna 23. Sodium Chloride 0.9% Flush 24. Sodium Chloride\n 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:40 PM\n MULTI LUMEN - START 04:51 PM\n : lasix 10mg x 2 given to prevent fluid overload, serial Hct\n stable, transfused 1 UPRBC for Hct of 22.6\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:11 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: 82 (77 - 90) bpm\n BP: 105/53(74) {93/48(65) - 118/101(106)} mmHg\n RR: 15 (11 - 23) insp/min\n SPO2: 96%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 92.4 kg (admission): 91.3 kg\n CVP: 9 (5 - 12) mmHg\n Total In:\n 2,495 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 2,025 mL\n Blood products:\n 350 mL\n Total out:\n 739 mL\n 34 mL\n Urine:\n 739 mL\n 34 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,756 mL\n -34 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ////\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, Distended, Tender: to palpation\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 188 K/uL\n 8.4 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 25.5 %\n 14.9 K/uL\n [image002.jpg]\n 02:27 PM\n 03:26 PM\n 03:35 PM\n 08:05 PM\n 11:44 PM\n 02:19 AM\n 05:54 AM\n 12:21 PM\n 06:35 PM\n 12:00 AM\n WBC\n 12.7\n 12.8\n 14.9\n Hct\n 22.0\n 20.1\n 24.5\n 24.7\n 22.6\n 26.2\n 26.6\n 25.5\n Plt\n 221\n 220\n 188\n Creatinine\n 0.6\n 0.7\n 0.7\n TCO2\n 30\n Glucose\n 119\n 143\n 128\n Other labs: PT / PTT / INR:13.2/25.9/1.1, Ca:8.7 mg/dL, Mg:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70 yo F discharged after gastroenteritis on\n lovenox and coumadin and presents with large rectus hematoma.\n Neurologic:\n -- AOX3\n -- pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular: -- CABG, MV mechanical on coumadin on hold for\n now\n -- reverse INR to < 2 with FFP\n -- HD stable\n -- lasix 10mg x 2 given to prevent fluid overload\n Pulmonary: --sating well on NC, encourage IS\n Gastrointestinal / Abdomen: -- NPO\n -- Rectus abominus sheath hematoma. Went to IR , unable to be\n embolized secondary to totuous vessels. Of note, no active bleeding\n seen during the procedure.\n -- zofran prn n/v\n -- bowel regimen: senna, colace\n -- GI prophy: famotidine\n -- consider placing NGT for decompression\n Nutrition: NPO\n Renal: -- foley in place, monitor UOP, Cr 0.7\n -- mucormyst x 2 doses\n Hematology: -- trend HCT q6h, INR q4h\n -- : vit K 2mg IV, 5 unit FFP, 2u PRBC\n -- : 1u PRBC HCt: 26.2-->26--> 25.5() (stable), INR 1.1\n -- goal INR < 2 until bleed resolved\n Endocrine: --cont levothyroxine,\n -- RISS\n Infectious Disease: no issues, afebrile, WBC 14.9 (slightly trending\n up) today pending\n Lines / Tubes / Drains: PIV x1, foley, left radial aline, RIJ CVL\n Wounds:\n Imaging:\n Fluids: LR @ 100cc/hr\n Consults: General surgery, IR\n Billing Diagnosis: Other: rectus sheath hematoma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:40 PM\n 20 Gauge - 04:06 PM\n Multi Lumen - 04:51 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2200-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 402153, "text": "TITLE:\n SICU\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Current medications:\n 1. IV access: Peripheral line Location: Left Order date: @ 1101\n 12. IV access request: Peripheral Place Indication: Blood products- Red\n cells Urgency: STAT Order date: @ 1101\n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 1655\n 13. IV access request: PICC Place Indication: Blood products- Red cells\n Urgency: STAT Order date: @ 1101\n 3. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 1106\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1115\n 4. Acetaminophen mg PO/NG Q6H:PRN pain/fever\n Do not exceed 4gm per day. Order date: @ 1101\n 15. Levothyroxine Sodium 125 mcg PO/NG DAILY Order date: @ 1101\n 5. Acetylcysteine 20% 600 mg PO/NG Order date: @ 1101\n 16. Ondansetron 4 mg IV Q8H:PRN n/v Order date: @ 1655\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1115\n 17. OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain Order date:\n @ 1217\n 7. Docusate Sodium 100 mg PO BID:PRN constipat Order date: @\n 1101\n 18. Phytonadione 2 mg IV ONCE Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 1101\n 8. Famotidine 20 mg PO/NG Q12H Order date: @ 1116\n 19. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 0825\n 9. Furosemide 10 mg IV 2X\n once now, and second dose after 1st unit of PRBC Order date: @\n 1610\n 20. Senna 1 TAB PO/NG :PRN constipation Order date: @ 1101\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1115\n 21. 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: @ 1101\n 11. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date:\n @ 1620\n 22. 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: @ 1655\n 24 Hour Events:\n - transferred to SICU. Given vit K 2mg IV, 5 unit FFP, 2u PRBC.\n RIJ CVL placed. Went to IR , unable to be embolized secondary to\n totuous vessels. Of note, no active bleeding seen during the procedure.\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:39 PM\n Hydromorphone (Dilaudid) - 04:30 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Flowsheet Data as of 03:49 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: 36.4\nC (97.6\n HR: 85 (76 - 96) bpm\n BP: 107/52(74) {98/49(4) - 141/67(89)} mmHg\n RR: 14 (10 - 22) insp/min\n SPO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 90.5 kg (admission): 91.3 kg\n CVP: 12 (3 - 16) mmHg\n Total In:\n 2,758 mL\n 280 mL\n PO:\n Tube feeding:\n IV Fluid:\n 954 mL\n 280 mL\n Blood products:\n 1,804 mL\n Total out:\n 1,582 mL\n 225 mL\n Urine:\n 1,462 mL\n 225 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,176 mL\n 55 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.40/46/108/29/2\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, Bowel sounds present, Distended, Tender: lower\n abdominal quadrants\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (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 188 K/uL\n 8.4 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.7 %\n 14.9 K/uL\n [image002.jpg]\n 02:27 PM\n 03:26 PM\n 03:35 PM\n 08:05 PM\n 11:44 PM\n 02:19 AM\n WBC\n 12.7\n 12.8\n 14.9\n Hct\n 22.0\n 20.1\n 24.5\n 24.7\n Plt\n 221\n 220\n 188\n Creatinine\n 0.6\n 0.7\n 0.7\n TCO2\n 30\n Glucose\n 119\n 143\n 128\n Other labs: PT / PTT / INR:13.7/24.6/1.2, Ca:8.7 mg/dL, Mg:2.1 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CT Abd: Active extravasation idicating arterial bleeding\n into left rectus hematoma from a branch of the left epigastric artery.\n Multiple rectus sheath abdominal wall hematomas, in a different\n configuration although not significantly changed in size. Hematoma in\n the extraperitoneal pelvic pre- and perivesical space, unchanged.\n Hemoperitoneum adjacent to the liver and in paracolic gutters, slightly\n increased when compared to prior exam. Right basilar atelectasis.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ASSESSMENT: 70 yo F discharged after gastroenteritis on lovenox and\n coumadin and presents with large rectus hematoma.\n Neurologic:\n -- AOX3\n -- pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular:\n -- CABG, MV mechanical \n -- reverse INR to < 2 with FFP\n -- HD stable\n -- lasix 10mg x 2 given to prevent fluid overload\n Pulmonary: sating well on NC, encourage IS\n Gastrointestinal / Abdomen:\n -- NPO\n -- rectus abominus sheath hematoma. Went to IR , unable to be\n embolized secondary to totuous vessels. Of note, no active bleeding\n seen during the procedure.\n -- zofran prn n/v\n -- bowel regimen: senna, colace\n -- GI prophy: famotidine\n -- consider placing NGT for decompression\n Nutrition: NPO\n Renal:\n -- foley in place, monitor UOP, Cr 0.7\n -- mucormyst \n Hematology:\n -- trend HCT q4h\n -- : vit K 2mg IV, 5 unit FFP, 2u PRBC\n -- goal INR < 2 until bleed resolved\n -- HCt 24.7 (stable), INR 1.2\n Endocrine: cont levothyroxine, RISS\n ID: no issues, afebrile, WBC 14.9 (slightly trending up)\n T/L/D: PIV x2, foley, right radial aline, RIJ CVL\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: gold surgery, IR\n Billing Diagnosis: rectus sheath hematoma\n Prophylaxis:\n DVT: boots\n Stress ulcer: famotidine\n VAP bundle: n/a\n Comments: ICU consent completed\n Communication: daughter \n status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402156, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Received pt in angio. Pt alert and oriented x3. No c/o pain.\n Intermittent nausea and positive emesis of approximately 120cc of\n green bilious emesis prior transger back to SICU post angio\n s/p in angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses palpable but weak/marked and Doppler used\n post angio protocol. Bedrest w/ right leg straight until 0200\n Total of 4uFFP given by RN.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Bilateral labia w/ bruising\n Tele in 1^st degree AV block. PR >.2. Frequenct PVCs. SBP\n >90\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units.\n HCT post 2uPRBC 24.5 (20.1). Serial HCTs Q4hrs\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Right groin benign. Pulses noted\n No further c/o nausea. Abd remains tender to palp. No\n request for PRN pain med\n HCT stable at 24.7. K 3.4\n 40meq IV KCL admin\n Tele remains in 1^st degree AV block. PVC frequency less\n since repletion of lytes.\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402215, "text": " Problem\n spontaneous rectus hematoma\n Assessment:\n A&ox3. SBP 90-130\ns. HR !st degree AVB 0.21 80-100\ns occasional PVC\n Abd Firm distended & tender. +BS X4. +flatus No BM.\n LS CTA. Sats 96-98% on RA.\n INR 1.2. HCT up from 22.6 to 26.2 after 1 unit PRBC\n U/O trending down 15-30cc/hr.\n Action:\n Dilaudid 0.5mg given X2 w/ adequate pain relief reported by patient.\n LR increased from 75 to 100.\n Serial HCT\ns and Inr\ns drawn\n Response:\n CVP 9-11.\n No change in U/O with increase in fluid.\n Pain well controlled w/ dilaudid.\n Plan:\n Continue to monitor INR Give FFP as ordered. Monitor serial HCT\ns and\n give PRBC\n Monitor U/O.\n Medicate w/ dilaudid for pain.\n Provide Emotional support to pt and family\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402209, "text": " Problem\n spontaneous rectus hematoma\n Assessment:\n A&ox3. SBP 90-130\ns. HR !st degree AVB 0.21 80-100\ns occasional PVC\n Abd Firm distended & tender. +BS X4. +flatus No BM.\n LS CTA. Sats 96-98% on RA.\n INR 1.2. HCT up from 22.6 to 26.2 after 1 unit PRBC\n U/O trending down 15-30cc/hr.\n Action:\n Dilaudid 0.5mg given X2 w/ adequate pain relief reported by patient.\n LR increased from 75 to 100.\n Serial HCT\ns and Inr\ns drawn\n Response:\n CVP 9-11.\n No change in U/O with increase in fluid.\n Pain well controlled w/ dilaudid.\n Plan:\n Continue to monitor INR Give FFP as ordered. Monitor serial HCT\ns and\n give PRBC\n Monitor U/O.\n Medicate w/ dilaudid for pain.\n Provide Emotional support to pt and family\n" }, { "category": "Physician ", "chartdate": "2200-02-11 00:00:00.000", "description": "Intensivist Note", "row_id": 402364, "text": "SICU\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further management\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Current medications:\n Vitamin D, Lipitor 80 mg PO Daily, Fiorinal Prn headache, Aspirin 81 mg\n PO Daily, Lisinopril 20 mg PO Daily, Clindamycin for dental work,\n Metoprolol 50 mg PO BID, Synthroid 125 mcg PO Daily and 250 mch\n Wednesday and Sunday, Coumadin 5 mg PO Daily\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:54 AM\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 10:00 AM\n Other medications:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 82 (76 - 92) bpm\n BP: 123/59(73) {97/47(64) - 146/76(80)} mmHg\n RR: 19 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 92.4 kg (admission): 91.3 kg\n CVP: 0 (0 - 13) mmHg\n Total In:\n 2,205 mL\n 586 mL\n PO:\n 150 mL\n 80 mL\n Tube feeding:\n IV Fluid:\n 2,055 mL\n 506 mL\n Blood products:\n Total out:\n 1,449 mL\n 130 mL\n Urine:\n 1,449 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 756 mL\n 456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 307 K/uL\n 9.5 g/dL\n 85 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.4 %\n 10.4 K/uL\n [image002.jpg]\n 02:19 AM\n 05:54 AM\n 12:21 PM\n 06:35 PM\n 12:00 AM\n 03:01 AM\n 09:52 AM\n 04:27 PM\n 10:41 PM\n 03:47 AM\n WBC\n 14.9\n 10.5\n 10.4\n Hct\n 24.7\n 22.6\n 26.2\n 26.6\n 25.5\n 26.1\n 28.7\n 27.1\n 27.6\n 28.4\n Plt\n 188\n 218\n 307\n Creatinine\n 0.7\n 0.6\n 0.6\n Glucose\n 128\n 90\n 85\n Other labs: PT / PTT / INR:12.9/23.4/1.1, Ca:9.0 mg/dL, Mg:1.9 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70F discharged after gastroenteritis on lovenox\n and coumadin with large rectus sheath hematoma\n Neurologic:\n n AAOX3\n n pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular:\n n CABG, MV mechanical on coumadin, held currently\n n HD stable\n n Given risk of thrombus from mechanical valve, and stable HCT\n cardiology feels that it is best to restart anticoagulation with\n heparin drip, and if stable over 48 hours or so, restart coumadin.\n After discussing w/ primary team, plan to restart heparin drip in\n AM.\n Pulmonary:\n n sat'ing well on RA\n n IS\n Gastrointestinal / Abdomen:\n n rectus abominus sheath hematoma. Went to IR , unable to be\n embolized secondary to totuous vessels. Of note, no active bleeding\n seen during the procedure.\n Nutrition:\n Advance\n Renal:\n Stable\n Hematology:\n HCT and INR stable . If plan to restart heparin today,\n continue to check HCT q 8 hrs.\n goal INR < 2 until bleed resolved\n Endocrine\n RISS with good blood control\n On synthroid\n Infectious Disease: no issues, afebrile\n Lines / Tubes / Drains: PIV x1, RIJ CVL\n Consults: General surgery, Cardiology, IR\n Billing Diagnosis:\n ICU Care\n Lines:\n 20 Gauge - 04:06 PM\n Multi Lumen - 04:51 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: transfer now\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 402379, "text": "70y F with PMHx of CAD s/p CABG, MVR on coumadin. Recent admission\n for gastroenteritis, then re-admitted with worsening\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt\n with hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC,\n 1u FFP. CT Abd showed active bleeding into the rectus sheath hematoma >\n patient was transferred to ICU for futher management. Patient went to\n IR, but they were to embolize.\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 402380, "text": "70y F with PMHx of CAD s/p CABG, MVR on coumadin. Recent admission\n for gastroenteritis, then re-admitted with worsening\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt\n with hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC,\n 1u FFP. CT Abd showed active bleeding into the rectus sheath hematoma >\n patient was transferred to ICU for futher management. Patient went to\n IR, but they were to embolize.\n Bilateral Rectus Sheath Hematomas\n Assessment:\n Pt alert and oriented x3. C/o generalized pain especially to\n LLE d/t arthritis .\n s/p angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal placed at time of angio. Pulses\n palpable.\n Stable HCT x24 hrs\n Abd softly distended, +BS and +flatus\n Tele in 1^st degree AV block. PR >.2. Occassional PVCs. NBP\n stable.\n LSCTA and sats >95% on 2Liters via NC\n Voiding on commode adequate amounts.\n Action:\n Oxymoron PO for c/o generalized discomfort (arthritic pain)\n IV hep locked.\n Heparin drip started today in setting of MVR.\n Diet advanced to heart healthy.\n OOB to ambulate today.\n Response:\n Right groin benign. Pulses noted\n Pt states adequate pain relief from PRN oxycodone.\n Tele remains in 1^st degree AV block w/ occasional PVCs\n Tolerating regular diet, denies nausea. +flatus.\n Feels tired after ambulation, but able to ambulate 50+feet\n in hallway with minimal assist.\n Plan:\n Needs coags at 1530\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n Encourage PO intake\n Enc OOB to increase strength.\n Start coumadin this afternoon.\n Titrate heparin drip to therapeautic level\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 402381, "text": "70y F with PMHx of CAD s/p CABG, MVR on coumadin. Recent admission\n for gastroenteritis, then re-admitted with worsening\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt\n with hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC,\n 1u FFP. CT Abd showed active bleeding into the rectus sheath hematoma >\n patient was transferred to ICU for futher management. Patient went to\n IR, but they were to embolize.\n Bilateral Rectus Sheath Hematomas\n Assessment:\n Pt alert and oriented x3. C/o generalized pain especially to\n LLE d/t arthritis .\n s/p angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal placed at time of angio. Pulses\n palpable.\n Stable HCT x24 hrs\n Abd softly distended, +BS and +flatus\n Tele in 1^st degree AV block. PR >.2. Occassional PVCs. NBP\n stable.\n LSCTA and sats >95% on 2Liters via NC\n Voiding on commode adequate amounts.\n Action:\n Oxymoron PO for c/o generalized discomfort (arthritic pain)\n IV hep locked.\n Heparin drip started today in setting of MVR.\n Diet advanced to heart healthy.\n OOB to ambulate today.\n Response:\n Right groin benign. Pulses noted\n Pt states adequate pain relief from PRN oxycodone.\n Tele remains in 1^st degree AV block w/ occasional PVCs\n Tolerating regular diet, denies nausea. +flatus.\n Feels tired after ambulation, but able to ambulate 50+feet\n in hallway with minimal assist.\n Plan:\n Needs coags at 1530\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n Encourage PO intake\n Enc OOB to increase strength.\n Start coumadin this afternoon.\n Titrate heparin drip to therapeautic level\n Demographics\n Attending MD:\n G.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Height:\n Admission weight:\n 91.3 kg\n Daily weight:\n 92.4 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Precautions:\n CV-PMH: Hypertension\n Additional history: Past Medical History: 1st degree AV block and\n episodes of 2nd\n degree AV block (Wenckiebach), Hypertension, hemolytic anemia;\n ?TIA when she had endocarditis 18 yrs ago, Hypothyroidism,\n Hyperlipidemia, Osteoarthritis, Hashimoto thyroiditis\n .\n Past Surgical History: Coronary artery bypass, mechanical MVR\n , reoperative MVR St. , open tubal ligation\n .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:117\n D:69\n Temperature:\n 98.8\n Arterial BP:\n S:135\n D:64\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,095 mL\n 24h total out:\n 480 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:47 AM\n Potassium:\n 3.8 mEq/L\n 03:47 AM\n Chloride:\n 101 mEq/L\n 03:47 AM\n CO2:\n 29 mEq/L\n 03:47 AM\n BUN:\n 13 mg/dL\n 03:47 AM\n Creatinine:\n 0.6 mg/dL\n 03:47 AM\n Glucose:\n 85 mg/dL\n 03:47 AM\n Hematocrit:\n 28.4 %\n 03:47 AM\n Finger Stick Glucose:\n 137\n 10:00 AM\n Valuables / Signature\n Other valuables: cell phone and charger\n Transferred from: SICU B\n Transferred to: 918\n Date & time of Transfer: 1400\n" }, { "category": "Nursing", "chartdate": "2200-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402139, "text": "HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n" }, { "category": "Nursing", "chartdate": "2200-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402140, "text": "HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n Problem\n spontaneous rectus hematoma\n Assessment:\n A&ox3. SBP 90-130\ns. HR 80-100\ns occasional PVC\n Abd Firm tender. +BS X4. +flatus No BM.\n LS CTA. Sats 96-98% on RA this am by afternoon down to 90.\n C/O pain in ABD\n INR 3.3 on adm to unit. HCT in afternoon down to 22 from 28.6\n U/O trending down 15-30cc/hr.\n Action:\n A-line /CVL placed. CVL confirmed by cxray.\n Received 4 units FFP/ 10mg vitamin K.\n 10mg iv Lasix given prior to 3^rd unit of FFP.\n Morphine given IV X2 with little effect. 5mg po roxicodone give w/\n little effect.\n Dilaudid 0.5mg given X3 w/ adequate pain relief reported by patient.\n LR heplocked. While receiving products.\n 2L NC placed.\n Down to IR for angiogram @1800\n Response:\n O2 sat up to 98%.\n CVP 7-9. Urine output up to 100cc/hr.\n Pain well controlled w/ dilaudid.\n Due for 2 units of PRBC\n Plan:\n Continue to monitor INR Give FFP as ordered. Monitor serial HCT\ns and\n give PRBC\n Monitor U/O.\n Medicate w/ dilaudid for pain.\n Provide Emotional support to pt and family\n" }, { "category": "Nursing", "chartdate": "2200-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402141, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Received pt in angio. Pt alert and oriented x3. No c/o pain.\n Intermittent nausea and positive emesis of approximately 120cc of\n green bilious emesis prior transger back to SICU post angio\n s/p in angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses weak/marked and Doppler used post angio\n protocol. Bedrest w/ right leg straight until 0200\n Total of 4uFFP given by RN.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Tele SR w/ high frequency of PVCs. SBP >100\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n" }, { "category": "Nursing", "chartdate": "2200-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402143, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Received pt in angio. Pt alert and oriented x3. No c/o pain.\n Intermittent nausea and positive emesis of approximately 120cc of\n green bilious emesis prior transger back to SICU post angio\n s/p in angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses weak/marked and Doppler used post angio\n protocol. Bedrest w/ right leg straight until 0200\n Total of 4uFFP given by RN.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Tele SR w/ high frequency of PVCs. SBP >100\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units.\n HCT post 2uPRBC 24.5\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n" }, { "category": "Physician ", "chartdate": "2200-02-08 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 402130, "text": "TITLE:\n Chief Complaint: rectus hematoma\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n Other medications:\n 1. IV access: Peripheral line Location: Left Order date: @ 1101\n 12. IV access request: Peripheral Place Indication: Blood products- Red\n cells Urgency: STAT Order date: @ 1101\n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 1655\n 13. IV access request: PICC Place Indication: Blood products- Red cells\n Urgency: STAT Order date: @ 1101\n 3. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 1106\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1115\n 4. Acetaminophen mg PO/NG Q6H:PRN pain/fever\n Do not exceed 4gm per day. Order date: @ 1101\n 15. Levothyroxine Sodium 125 mcg PO/NG DAILY Order date: @ 1101\n 5. Acetylcysteine 20% 600 mg PO/NG Order date: @ 1101\n 16. Ondansetron 4 mg IV Q8H:PRN n/v Order date: @ 1655\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1115\n 17. OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain Order date:\n @ 1217\n 7. Docusate Sodium 100 mg PO BID:PRN constipat Order date: @\n 1101\n 18. Phytonadione 2 mg IV ONCE Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 1101\n 8. Famotidine 20 mg PO/NG Q12H Order date: @ 1116\n 19. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 0825\n 9. Furosemide 10 mg IV 2X\n once now, and second dose after 1st unit of PRBC Order date: @\n 1610\n 20. Senna 1 TAB PO/NG :PRN constipation Order date: @ 1101\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1115\n 21. 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: @ 1101\n 11. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date:\n @ 1620\n 22. 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: @ 1655\n Post operative day:\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:39 PM\n Furosemide (Lasix) - 04:30 PM\n Hydromorphone (Dilaudid) - 04:30 PM\n Past medical history:\n Family / Social history:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Flowsheet Data as of 05:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 94 (88 - 94) bpm\n BP: 127/67(89) {121/53(4) - 141/67(89)} mmHg\n RR: 15 (15 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.3 kg\n CVP: 3 (3 - 3)mmHg\n Total In:\n 1,067 mL\n PO:\n TF:\n IVF:\n 498 mL\n Blood products:\n 569 mL\n Total out:\n 0 mL\n 260 mL\n Urine:\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 807 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.40/46/108/28/2\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, distended lower quandrants with\n tenderness to palpation\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.0 %\n 12.7 K/uL\n [image002.jpg]\n 02:27 PM\n 03:26 PM\n 03:35 PM\n WBC\n 12.7\n Hct\n 22.0\n Plt\n 221\n Cr\n 0.6\n TCO2\n 30\n Glucose\n 119\n Other labs: PT / PTT / INR:20.2/29.0/1.9, Ca++:8.5 mg/dL, Mg++:1.6\n mg/dL, PO4:2.8 mg/dL\n Imaging: CT Abd: Active extravasation idicating arterial bleeding\n into left rectus hematoma from a branch of the left epigastric artery.\n Multiple rectus sheath abdominal wall hematomas, in a different\n configuration although not significantly changed in size. Hematoma in\n the extraperitoneal pelvic pre- and perivesical space, unchanged.\n Hemoperitoneum adjacent to the liver and in paracolic gutters, slightly\n increased when compared to prior exam. Right basilar atelectasis.\n Assessment and Plan\n Assessment And Plan: 70 yo F discharged after gastroenteritis on\n lovenox and coumadin and presents with large rectus hematoma.\n Neurologic: -- AOX3\n -- pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular: -- CABG, MV mechanical \n -- reverse INR to < 2\n -- HD stable\n -- consider lasix if volume overloaded on physical exam\n Pulmonary: -- sating well on RA, encourage IS\n Gastrointestinal: -- rectus abominus sheath hematoma - plan for IR\n guided embolization once INR corrected\n Renal: -- foley in place, monitor UOP, Cr 0.7\n Hematology: -- trend HCT q4h\n -- vit K 2mg, 2 unit FFP\n -- goal INR < 2 until bleed resolved\n Infectious Disease: -- no issues, afebrile, WBC 12.4\n Endocrine: -- cont levothyroxine, RISS\n Fluids: -- LR @ 75cc/hr\n Electrolytes: -- check and replete as needed\n Nutrition: -- NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:40 PM\n 20 Gauge - 04:06 PM\n Multi Lumen - 04:51 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2200-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 402248, "text": "SICU\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n .\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Current medications:\n 1. 2. 3. 1000 mL LR 4. Acetaminophen 5. Calcium Gluconate 6. Dextrose\n 50% 7. Docusate Sodium 8. Famotidine 9. Furosemide 10. Glucagon 11.\n HYDROmorphone (Dilaudid) 12. 13. 14. Insulin 15. Levothyroxine Sodium\n 16. Magnesium Sulfate 17. Ondansetron 18. OxycoDONE (Immediate Release)\n 19. Pneumococcal Vac Polyvalent 20. Potassium Chloride 21. Potassium\n Phosphate 22. Senna 23. Sodium Chloride 0.9% Flush 24. Sodium Chloride\n 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:40 PM\n MULTI LUMEN - START 04:51 PM\n : lasix 10mg x 2 given to prevent fluid overload, serial Hct\n stable, transfused 1 UPRBC for Hct of 22.6\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:11 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: 82 (77 - 90) bpm\n BP: 105/53(74) {93/48(65) - 118/101(106)} mmHg\n RR: 15 (11 - 23) insp/min\n SPO2: 96%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 92.4 kg (admission): 91.3 kg\n CVP: 9 (5 - 12) mmHg\n Total In:\n 2,495 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 2,025 mL\n Blood products:\n 350 mL\n Total out:\n 739 mL\n 34 mL\n Urine:\n 739 mL\n 34 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,756 mL\n -34 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ////\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, Distended, Tender: to palpation\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 188 K/uL\n 8.4 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 25.5 %\n 14.9 K/uL\n [image002.jpg]\n 02:27 PM\n 03:26 PM\n 03:35 PM\n 08:05 PM\n 11:44 PM\n 02:19 AM\n 05:54 AM\n 12:21 PM\n 06:35 PM\n 12:00 AM\n WBC\n 12.7\n 12.8\n 14.9\n Hct\n 22.0\n 20.1\n 24.5\n 24.7\n 22.6\n 26.2\n 26.6\n 25.5\n Plt\n 221\n 220\n 188\n Creatinine\n 0.6\n 0.7\n 0.7\n TCO2\n 30\n Glucose\n 119\n 143\n 128\n Other labs: PT / PTT / INR:13.2/25.9/1.1, Ca:8.7 mg/dL, Mg:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70 yo F discharged after gastroenteritis on\n lovenox and coumadin and presents with large rectus hematoma.\n Neurologic:\n -- AOX3\n -- pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular: -- CABG, MV mechanical on coumadin on hold for\n now\n we will talk to the team about risk:benefit ration of bleeding vs\n risk of embolization secondary to mechanical valve.\n -- reverse INR to < 2 with FFP\n -- HD stable\n -- lasix 10mg x 2 given to prevent fluid overload\n Pulmonary: --sating well on NC, encourage IS\n Gastrointestinal / Abdomen: -- NPO\n -- Rectus abominus sheath hematoma. Went to IR , unable to be\n embolized secondary to totuous vessels. Of note, no active bleeding\n seen during the procedure.\n -- zofran prn n/v\n -- bowel regimen: senna, colace\n -- GI prophy: famotidine\n -- consider placing NGT for decompression\n Nutrition: NPO\n Renal: -- foley in place, monitor UOP, Cr 0.7\n -- mucormyst x 2 doses\n Hematology: -- trend HCT q6h, INR q4h\n -- : vit K 2mg IV, 5 unit FFP, 2u PRBC\n -- : 1u PRBC HCt: 26.2-->26--> 25.5() (stable), INR 1.1\n -- goal INR < 2 until bleed resolved\n Endocrine: --cont levothyroxine,\n -- RISS\n Infectious Disease: no issues, afebrile, WBC 14.9 (slightly trending\n up) today pending\n Lines / Tubes / Drains: PIV x1, foley, left radial aline, RIJ CVL\n Wounds:\n Imaging:\n Fluids: LR @ 100cc/hr\n Consults: General surgery, IR\n Billing Diagnosis: Other: rectus sheath hematoma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:40 PM\n 20 Gauge - 04:06 PM\n Multi Lumen - 04:51 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2200-02-10 00:00:00.000", "description": "Cardiology Consult", "row_id": 402262, "text": "TITLE: DIVISION OF CARDIOLOGY COMPREHENSIVE CONSULTATION NOTE\n CHIEF COMPLAINT: Patient is seen in consultation today at the request\n of Dr. . We are asked to give consultative advice regarding\n evaluation and management of anticoagulation.\n HISTORY OF PRESENT ILLNESS:\n 70F CAD s/p CABG, s/p mechanical MVR, HTN admitted with rectus sheath\n hematoma and active bleeding from left epigastric artery. She was\n admitted from with gastroeneteritis and discharged home on\n cipro and flagyl for small bowel thickening on CT. She returned on \n with sudden abdominal pain. A rectus sheath hematoma was noted on CT.\n Her INR was 4.2 on admission and she intially was hypotensive (BP\n responded to 1L NS). A repeat CT abd showed active extravasation from\n the L epigastric artery. IR was initially unable to perform\n embolization due to her supratherapeutic INR; she was reversed with FFP\n and vitamin K. She was transferred to the ICU on , had another\n attempt at embolization once her INR had decreased however this was\n unsuccessful. She has since then been managed conservatively with an\n INR<2 and has had stable hematocrits over the past 24 hours.\n On cardiac review of symptoms, she denies any chest pain or discomfort,\n palpitations or syncope/pre-syncope. She notes increase lower extremity\n edema but no orthopnea or paroxysmal nocturnal dyspnea.\n PAST MEDICAL HISTORY:\n -s/p mechanical MVR (for endocarditis), reoperative MVR St. \n \n -AV prolongation and episodes of 2nd degree AV block Wenckiebach\n -HTN\n -hemolytic anemia\n -TIA when she had endocarditis 18 yrs ago\n -Hypothyroidism\n -Hyperlipidemia\n -OA\n -Hashimoto thyroiditis\n -open tubal ligation\n Cardiac Risk Factors include HTN, CAD, HL.\n HOME MEDICATIONS:\n Lipitor 80mg qday\n Lovenox 120mg qday\n HCTZ 12.5mg qday\n Levothyroxine 125mcg qday\n Lisinopril 20mg qday\n Metoprolol Tartrate 50mg \n Cipro 250mg until \n Metronidazole 500mg until \n Coumadin 5mg alternating with 7.5mg daily\n ASA 81mg daily\n CURRENT MEDICATIONS:\n Insulin SC\n Levothyroxine Sodium 125 mcg PO/NG DAILY\n Famotidine 20 mg PO/NG Q12H\n ALLERGIES: PCN/cephalosporins/vanc\n SOCIAL HISTORY:\n Married. Has 4 daughters, has grandchildren. Family involved. Lives\n with husband in . Retired. Like to go down to a nearby beach with\n her husband. Denies smoking, alcohol, drugs.\n FAMILY HISTORY:\n father passed away from MI in his 70s, mom passed away from CHF in her\n 70s. no sudden cardiac death.\n REVIEW OF SYSTEMS:\n Constitutional: +fevers, chills No nightsweats, unintentional weight\n change, or fatigue.\n Eyes: No blurry vision, double vision, or loss of vision.\n ENT: No bleeding from the nose or gums, nasal drainage or discharge,\n dry mouth, or oral ulcers.\n Heme/Lymph: No recurrent infections, history of DVT. Anemia, arterial\n bleeding.\n Respiratory: No hemoptysis, wheezing, cough, or shortness of breath.\n Gastrointestinal: No diarrhea, constipation, hematochezia, melena,\n nausea, vomiting. +abdominal pain.\n Integumentary: No rashes, petechiae, ecchymoses, or ulcers.\n Allergic/Immunology: No allergies or immunosuppression.\n Psychiatric: No suicidal ideation, delusions, hallucinations,\n depression, or sleep disorder.\n Genitourinary: No dysuria, hematuria, dark urine, cloudy urine, or\n history of UTIs.\n Neurological: No numbness, tingling, loss of sensation, weakness,\n headache, or abnormal movements.\n Musculoskeletal: No joint swelling, myalgias. +knee pain.\n Endocrine: No excessive sweating, dry skin or hair, hot, or cold\n intolerance. +history of hypothyroidism\n ALL OTHER SYSTEMS NEGATIVE EXCEPT AS NOTED ABOVE\n PHYSICAL EXAMINATION\n Vitals: T: 96.8 degrees Fahrenheit, BP: 120/51 mmHg supine, HR 92 bpm,\n RR 18 bpm, O2: 93% on NC.\n Gen: Pleasant, well appearing female in NAD\n Eyes: No conjunctival pallor. No icterus.\n ENT: MMM. OP clear.\n CV: JVP 8-10cm. Normal carotid upstroke without bruits. RRR. nl S1, S2.\n II/VI systolic crescendo-decrescendo mumur at RUSH. No rubs, clicks, or\n gallops. Full distal pulses bilaterally.\n LUNGS: crackle L base and diminished BS r base.\n ABD: NABS. mild TTP. Soft, ND. No HSM.\n Heme/Lymph/Immune: + . No CC, no cervical\n lymphadenopathy.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. CN 2-12 grossly intact. Gait assessment deferred\n PSYCH: Mood and affect were appropriate.\n TELEMETRY: sinus 80s with occassional PVCs\n ECG: multiple ECGs with sinus rhythm 70s, occassional PVCs, PR 240\n TRANSTHORACIC ECHOCARDIOGRAM :\n The left atrium is mildly dilated. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%) Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. No aortic regurgitation is seen. A bileaflet mitral\n valve prosthesis is present. The mitral prosthesis appears well seated,\n with normal leaflet/disc motion and transvalvular gradients. No mitral\n regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen.\n There is mild pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Normal mechanical mitral prosthesis. Preserved global and\n regional biventricular systolic function. Moderate tricuspid\n regurgitation. Mild pulmonary hypertension.\n CARDIAC CATHETERIZATION :\n 1. SElective coronary angiography revealed a right dominant system.\n LMCA and proximal LAD were normal. There was an 80% ostial D1 stenosis\n (large vessel). LCx was normal and RCA had a 20% ostial lesion.\n 2. Left ventriculography showed EF of 70%. There was 3+ MR. There were\n no wall motion abnormalities.\n 3. Hemodynamic assessment showed PCWP of 14 mm Hg and V-waves upto 30\n mm Hg. There was moderate pulmonary hypertension with Pap of 50/7 mm\n Hg. There was a 12 mm Hg gradient across the mitral valve.\n ETT none:\n OTHER TESTING:\n IR PROC :\n No active extravasation identified. Proximal left inf. epigastric\n tortuous, thus could not selectively catheterize distal enough for safe\n embolization. Right femoral puncture site with angioseal left in place.\n Pt. left dept stable condition.\n CXR :\n Tip of the new right internal jugular line projects over the junction\n of brachiocephalic veins. Right hemidiaphragm is elevated, a new\n development over the past five years. At least moderate intestinal\n distention is seen in the upper abdomen, is not responsible since the\n left hemidiaphragm is in standard placement. Left lung is clear.\n Patient has had median sternotomy and mitral valve replacement. Heart\n is mildly enlarged, but unchanged and there is no pulmonary vascular\n re-distribution, edema, or appreciable pleural effusion.\n CT C/A/P :\n 1. Active extravasation idicating arterial bleeding into left rectus\n hematoma from a branch of the left epigastric artery. Multiple rectus\n sheath abdominal wall hematomas, in a different configuration although\n not significantly changed in size. Hematoma in the extraperitoneal\n pelvic pre- and perivesical space, unchanged.\n 2. Hemoperitoneum adjacent to the liver and in paracolic gutters,\n slightly increased when compared to prior exam.\n 3. Right basilar atelectasis.\n CT C/A/P :\n 1. Interval development of new bilateral rectus abdominis hematomas.\n Superinfection of these fluid collections cannot be excluded. Linear\n hyperdensity in between fluid-fluid level of one of the hematomas is\n identified and may represent active extravasation. If clinical concern\n for active extravasation exists, repeat delayed imaging or angiography\n should be performed.\n 2. Small amount of high-density fluid in the right paracolic gutter,\n similar in appearance.\n 3. Mild biliary prominence, unchanged.\n 4. Renal and splenic hypodensities, incompletely characterized.\n Dedicated renal/spleen ultrasound is recommended on nonurgent basis.\n 5. Interval improvement in small bowel wall thickening as compared to\n prior exam.\n LABORATORY DATA:\n 138 106 13\n ------------<90\n 4.1 28 0.6\n Ca: 8.7 Mg: 2.0 P: 2.2\n 10.5 > 8.9 < 218\n Hct: 24.5->24.7-> 22.6->26.2->26.6-> 25.5->26.1->28.7\n PT: 13.1 PTT: 24.8 INR: 1.1 (less than 2 since )\n ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY\n ROUNDS:\n 70F with h/o MVR x2, AF admitted with rectus sheath hematoma and\n extravasation from L epigastric artery which required reversal of her\n INR. She has now had stable hematocrits over the past 24 hours.\n In terms of her thrombosis risk, she is at high risk for thrombosis\n given her mechanical mitral valve. It is difficult to quantify an exact\n percentage risk. The risk of not resuming anticoagulation is thrombosis\n and embolization, whereas recurrent bleeding could occur if\n anticoagulation is restarted.\n Given that her hematocrit has been stable and her mechanical MVR places\n her at higher risk of thromboembolism, she should be restarted on a\n heparin gtt. If her hematocrit begins to drop again or she shows signs\n of bleeding the heparin can be stopped quickly. If her hematocrit\n remains stable over the next 48 hours on the heparin gtt then she can\n be transitioned to warfarin.\n Recommendations:\n -high thrombosis risk with mechanical mitral valve\n -given stable Hct, would start heparin gtt\n -if Hct stable over next 48 hours would restart warfarin with goal INR\n 2.5-3.5\n This patient was seen and discussed with and will be evaluated by Dr.\n . Please see his note in the inpatient medical record / OMR /\n Metavision for additional comments.\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402320, "text": " Problem - Description In Comments\n Assessment:\n Pt A&O x 3. PERRL. Pt c/o LLE pain. Pt remains on Q 6 hour hct\n and INR checks. Pt hemodynamically stable throughout shift.\n Occasional PVC\ns noted during shift. Team aware.\n Action:\n Given 5mg Oxycodone at 2300.\n Response:\n Pt slept throughout night. No further c/o pain or discomfort. 0400\n hct 28.4.\n Plan:\n ? call out\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402322, "text": " Problem - Description In Comments\n Assessment:\n Pt A&O x 3. PERRL. Pt c/o LLE pain. Pt remains on Q 6 hour hct\n and INR checks. Pt hemodynamically stable throughout shift.\n Occasional PVC\ns noted during shift. Team aware.\n Action:\n Given 5mg Oxycodone at 2300.\n Response:\n Pt slept throughout night. No further c/o pain or discomfort. 0400\n hct 28.4.\n Plan:\n ? call out\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402327, "text": " Problem - Description In Comments\n Assessment:\n Pt A&O x 3. PERRL. Pt c/o LLE pain. Pt remains on Q 6 hour hct\n and INR checks. Pt hemodynamically stable throughout shift.\n Occasional PVC\ns noted during shift. Team aware.\n Action:\n Given 5mg Oxycodone at 2300.\n Response:\n Pt slept throughout night. No further c/o pain or discomfort. 0400\n hct 28.4, INR 1.1\n Plan:\n ? call out\n con\nt Q 6 hour INR and hct checks. Monitor for pain.\n" }, { "category": "Physician ", "chartdate": "2200-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 402174, "text": "TITLE:\n SICU\n HPI:\n 70y F with PMHX of CAD s/p CABG, MVR on coumadin admitted with\n abdominal pain and was found to have a large bilateral rectus sheath\n hematoma in the setting of INR = 4.4. Shortly after admission, pt with\n hypotension (SBP 80s) responsive to 1L NS. Pt transfused 2u PRBC, 1u\n FFP. CT Abd showed active bleeding into the rectus sheath hematoma. IR\n was , but as INR was still elevated at 3.3, they felt the risk\n of embolization now is too high and recommended more FFP prior to them\n performing procedure. Pt transferred to ICU for further\n management.\n Chief complaint:\n rectus hematoma\n PMHx:\n -- CAD s/p CABG\n -- mechanical MVR , reoperative MVR St. \n -- open tubal ligation\n -- hypothyroidism\n Current medications:\n 1. IV access: Peripheral line Location: Left Order date: @ 1101\n 12. IV access request: Peripheral Place Indication: Blood products- Red\n cells Urgency: STAT Order date: @ 1101\n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 1655\n 13. IV access request: PICC Place Indication: Blood products- Red cells\n Urgency: STAT Order date: @ 1101\n 3. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 1106\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1115\n 4. Acetaminophen mg PO/NG Q6H:PRN pain/fever\n Do not exceed 4gm per day. Order date: @ 1101\n 15. Levothyroxine Sodium 125 mcg PO/NG DAILY Order date: @ 1101\n 5. Acetylcysteine 20% 600 mg PO/NG Order date: @ 1101\n 16. Ondansetron 4 mg IV Q8H:PRN n/v Order date: @ 1655\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1115\n 17. OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain Order date:\n @ 1217\n 7. Docusate Sodium 100 mg PO BID:PRN constipat Order date: @\n 1101\n 18. Phytonadione 2 mg IV ONCE Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 1101\n 8. Famotidine 20 mg PO/NG Q12H Order date: @ 1116\n 19. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 0825\n 9. Furosemide 10 mg IV 2X\n once now, and second dose after 1st unit of PRBC Order date: @\n 1610\n 20. Senna 1 TAB PO/NG :PRN constipation Order date: @ 1101\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1115\n 21. 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: @ 1101\n 11. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain Order date:\n @ 1620\n 22. 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: @ 1655\n 24 Hour Events:\n - transferred to SICU. Given vit K 2mg IV, 5 unit FFP, 2u PRBC.\n RIJ CVL placed. Went to IR , unable to be embolized secondary to\n totuous vessels. Of note, no active bleeding seen during the procedure.\n Allergies:\n Penicillins\n Unknown;\n Vancomycin\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:39 PM\n Hydromorphone (Dilaudid) - 04:30 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Flowsheet Data as of 03:49 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: 36.4\nC (97.6\n HR: 85 (76 - 96) bpm\n BP: 107/52(74) {98/49(4) - 141/67(89)} mmHg\n RR: 14 (10 - 22) insp/min\n SPO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 90.5 kg (admission): 91.3 kg\n CVP: 12 (3 - 16) mmHg\n Total In:\n 2,758 mL\n 280 mL\n PO:\n Tube feeding:\n IV Fluid:\n 954 mL\n 280 mL\n Blood products:\n 1,804 mL\n Total out:\n 1,582 mL\n 225 mL\n Urine:\n 1,462 mL\n 225 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,176 mL\n 55 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.40/46/108/29/2\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, Bowel sounds present, Distended, Tender: lower\n abdominal quadrants- fullness L>R\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (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 188 K/uL\n 8.4 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.7 %\n 14.9 K/uL\n [image002.jpg]\n 02:27 PM\n 03:26 PM\n 03:35 PM\n 08:05 PM\n 11:44 PM\n 02:19 AM\n WBC\n 12.7\n 12.8\n 14.9\n Hct\n 22.0\n 20.1\n 24.5\n 24.7\n Plt\n 221\n 220\n 188\n Creatinine\n 0.6\n 0.7\n 0.7\n TCO2\n 30\n Glucose\n 119\n 143\n 128\n Other labs: PT / PTT / INR:13.7/24.6/1.2, Ca:8.7 mg/dL, Mg:2.1 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CT Abd: Active extravasation idicating arterial bleeding\n into left rectus hematoma from a branch of the left epigastric artery.\n Multiple rectus sheath abdominal wall hematomas, in a different\n configuration although not significantly changed in size. Hematoma in\n the extraperitoneal pelvic pre- and perivesical space, unchanged.\n Hemoperitoneum adjacent to the liver and in paracolic gutters, slightly\n increased when compared to prior exam. Right basilar atelectasis.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ASSESSMENT: 70 yo F discharged after gastroenteritis on lovenox and\n coumadin and presents with large rectus hematoma.\n Neurologic:\n -- AOX3\n -- pain control: tylenol prn, oxycodone prn, dilaudid prn\n Cardiovascular:\n -- CABG, MV mechanical \n -- reverse INR to < 2 with FFP\n -- HD stable\n -- lasix 10mg x 2 given to prevent fluid overload\n Pulmonary: sating well on NC, encourage IS\n Gastrointestinal / Abdomen:\n -- NPO\n -- rectus abominus sheath hematoma. Went to IR , unable to be\n embolized secondary to totuous vessels. Of note, no active bleeding\n seen during the procedure.\n -- zofran prn n/v\n -- bowel regimen: senna, colace\n -- GI prophy: famotidine\n -- consider placing NGT for decompression if vomiting .\n Nutrition: NPO\n Renal:\n -- foley in place, monitor UOP, Cr 0.7\n -- mucormyst \n Hematology:\n -- trend HCT q4h\n -- : vit K 2mg IV, 5 unit FFP, 2u PRBC\n -- goal INR < 2 until bleed resolved\n -- HCt 24.7 (stable), INR 1.2\n Endocrine: cont levothyroxine, RISS\n ID: no issues, afebrile, WBC 14.9 (slightly trending up)\n T/L/D: PIV x2, foley, right radial aline, RIJ CVL\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: gold surgery, IR\n Billing Diagnosis: rectus sheath hematoma\n Prophylaxis:\n DVT: boots\n Stress ulcer: famotidine\n VAP bundle: n/a\n Comments: ICU consent completed\n Communication: daughter \n status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2200-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402226, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Pt alert and oriented x3. C/o generalized pain especially to\n LLE d/t arthritis .\n s/p angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses palpable but weak/marked and Doppler used.\n HCT/INR being monitored Q6hrs. HCT stable 25-26. Goal INR\n <2.0.\n ABD slightly less firm/rigid/distended from night previous.\n Denies pain/nausea. Positive flatus\n Bilateral labia w/ bruising\n Tele in 1^st degree AV block. PR >.2. Occassional PVCs. SBP\n >100 by cuff. A-line positional and dampens but still able to draw\n blood\n LSCTA and sats >95% on 2Liters via NC\n Foley to gravity w/ borderline u/o 15-30cc/hr t/o day. SICU\n made aware and nsg to cont to monitor\n Action:\n HCT/INR Q6hrs\n Dilaudid 0.5mg IV x2 for c/o generalized discomfort\n Foley to gravity remained borderline\n Response:\n Right groin benign. Pulses noted\n Pt states adequate pain relief from PRN Dilaudid\n HCT stable at 26.6-25. INR 1.1\n Tele remains in 1^st degree AV block. PVC frequency less\n since repletion of lytes.\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n" }, { "category": "Nursing", "chartdate": "2200-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402227, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Pt alert and oriented x3. C/o generalized pain especially to\n LLE d/t arthritis .\n s/p angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses palpable but weak/marked and Doppler used.\n HCT/INR being monitored Q6hrs. HCT stable 25-26.6. Goal INR\n <2.0.\n ABD slightly less firm/rigid/distended from night previous.\n Denies pain/nausea. Positive flatus\n Bilateral labia w/ bruising\n Tele in 1^st degree AV block. PR >.2. Occassional PVCs. SBP\n >100 by cuff. A-line positional and dampens but still able to draw\n blood\n LSCTA and sats >95% on 2Liters via NC\n Foley to gravity w/ borderline u/o 15-30cc/hr t/o day. SICU\n made aware and nsg to cont to monitor\n Action:\n HCT/INR Q6hrs\n Dilaudid 0.5mg IV x2 for c/o generalized discomfort\n LR @100cc/hr . Foley to gravity remained borderline\n Response:\n Right groin benign. Pulses noted\n Pt states adequate pain relief from PRN Dilaudid\n HCT stable at 26.6-25. INR 1.1\n Tele remains in 1^st degree AV block w/ occasional PVCs\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Anti-coagulation still on hold per Surgery\n Pain mgt\n ? advance diet\n Enc OOB\n" }, { "category": "Nursing", "chartdate": "2200-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402316, "text": " Problem - Description In Comments\n Assessment:\n Pt A&O x 3. PERRL. Pt c/o LLE pain. Pt remains on Q 6 hour hct\n and INR checks. Pt hemodynamically stable throughout shift.\n Occasional PVC\ns noted during shift. Team aware.\n Action:\n Given 5mg Oxycodone at 2300.\n Response:\n Pt slept throughout night. No further c/o pain or discomfort.\n Plan:\n ? call out\n" }, { "category": "Nursing", "chartdate": "2200-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 402225, "text": "Bilateral Rectus Sheath Hematomas\n Assessment:\n Pt alert and oriented x3. C/o generalized pain especially to\n LLE d/t arthritis .\n s/p angio- Pelvic arteriogram and 2 inferior epigastric\n arteriograms. No active bleed seen. Unable to prophylactically embolize\n left inferior epigastric d/t very tenuous origin. Dr made aware.\n Angioseal closure to right groin used for hemostasis.\n Cllindamycin/Zofran admin during angio\n Right groin w/ angioseal/DSD/transparent dressing w/ small\n amt of SS drainge. Pulses palpable but weak/marked and Doppler used.\n HCT/INR being monitored Q6hrs. HCT stable 25-26. Goal INR\n <2.0.\n ABD firm/rigid/distended. Denied pain on initial exam but\n continues w/ intermittent nausea\n Bilateral labia w/ bruising\n Tele in 1^st degree AV block. PR >.2. Frequenct PVCs. SBP\n >90\n LSCTA and sats >95% on 2Liters via NC\n Action:\n Post angio groin checks per order\n Labs drawn upon arrival to floor. HCT 20.1 (22) INR 1.4 K\n 3.1 Mg 1.6\n 2uPRBC admin w/ Lasix 10mg IV b/t units.\n HCT post 2uPRBC 24.5 (20.1). Serial HCTs Q4hrs\n KCL 20meq IV x1 and 2gm MG IV x1\n Unable to give Mucomyst post procedure d/t intermittent\n nausea. SICU aware. No NGT. Evening dose held. BUN/Cr wnl and adequate\n u/o\n Response:\n Right groin benign. Pulses noted\n No further c/o nausea. Abd remains tender to palp. No\n request for PRN pain med\n HCT stable at 24.7. K 3.4\n 40meq IV KCL admin\n Tele remains in 1^st degree AV block. PVC frequency less\n since repletion of lytes.\n Plan:\n Serial HCTs. Monitor labs\n Hx of 1^st and 2^nd degree AV block monitor tele/lytes\n Pain mgt\n" }, { "category": "Radiology", "chartdate": "2200-02-08 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1123368, "text": ", D. MED SICU-B 6:04 PM\n OTHER EMBO Clip # \n Reason: please eval\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with 70 year old woman with rectus sheath hematoma, actively\n bleeding\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n PFI REPORT\n No active extravasation identified. Proximal left inf. epigastric tortuous,\n thus could not selectively catheterize distal enough for safe embolization.\n Right femoral puncture site with angioseal left in place. Pt. left dept\n stable condition.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-07 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1123200, "text": " 1:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for change in size in hematoma.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with rectus hematoma, elevated inr, blood pressure drop now.\n REASON FOR THIS EXAMINATION:\n please eval for change in size in hematoma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBRe FRI 4:26 PM\n Inrease of the left rectus sheath hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with rectus hematoma, elevated INR, blood\n pressure drop. Please evaluate for change in size of hematomas.\n\n COMPARISON: CT of the abdomen and pelvis with contrast from \n at 2:02 a.m. CT of the abdomen and pelvis from .\n\n TECHNIQUE: Non-enhanced MDCT images of the abdomen and pelvis were performed.\n Axial, coronal, and sagittal reformats were acquired.\n\n FINDINGS:\n\n The previously described right basilar ground glass opacity is improved.\n\n The previously described rectus sheath hematoma in the right rectus is\n essentially unchanged in size with the right rectus muscle measuring 2.5 x 2.7\n cm, unchanged from previous where it measured 2.5 x 2.7 cm as well. There is\n a small 13 x 11 mm measuring hyperdense focus within the right rectus muscle\n representing blood which is also unchanged in size from the prior.\n Again seen are two components of a left rectus sheath hematoma. The\n previously mainly hypodense-appearing anterior component of the left rectus\n sheath hematoma is currently hyperdense meaning the amount of blood within\n this lesion has increased. The lesion has also increased in size, currently\n measuring 6.1 (TRV) x 5.6 (AP) cm from previously 5.5 x 5.0 cm. The second\n component of the left rectus sheath hematoma is posterior to the first\n component and has also increased in size, currently measuring from previously\n 8.4 (TRV) x 6.0 (AP) from previously 7.6 x 6 cm. This posterior component\n extends inferiorly beyond the insertion of the rectus abdominis muscle at the\n superior pubic ramus into the pre- and perivesical space. The craniocaudal\n dimension of this posterior component of the left rectus sheath hematoma has\n increased from previously 11 cm to currently 16 cm with increase of the\n extraperitoneal pre- and perivesical component. There is no free fluid in the\n cul-de-sac. There are unchanged minimal amounts of fluid in the paracolic\n gutters bilaterally. There is no evidence of retroperitoneal bleed and there\n are no additional foci of bleeding.\n\n The previously described mild biliary prominence of the liver has resolved.\n The liver is normal. There is a small non-obstructing gallstone at the\n gallbladder neck. There is no intra- or extra-hepatic biliary duct\n (Over)\n\n 1:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for change in size in hematoma.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n dilatation. Unchanged ill-defined hypodensities in the spleen. Unchanged\n multiple hypodensities in the kidneys, with the largest at the mid pole\n measuring 1.4 cm, with a Hounsfield unit measurement of 13, representing a\n simple cyst. The adrenal glands are normal bilaterally. Pancreas is normal.\n There is no portocaval, retroperitoneal or mesenteric lymphadenopathy.\n\n The esophagus, small and large bowel are normal.\n\n No free air.\n\n CT OF THE PELVIS: As described above, there is extension of the left rectus\n sheath hematoma to the pre- and perivesical space bilaterally which is\n increased compared to prior exam. There are no pathologically enlarged pelvic\n lymph nodes. The urinary bladder is slightly displaced from the pre- and\n peri-vesical hematoma component. No pelvic hernias. There is no fluid in the\n cul-de-sac. The uterus is normal.\n\n BONES: There are mild degenerative changes in the lower lumbar spine with\n intervertebral disc disease at L5/S1. There are no suspicious focal lytic or\n sclerotic lesions.\n\n IMPRESSION:\n 1. There is increase in size of the left rectus sheath hematoma in both\n transverse, AP and craniocaudal dimension with an increase of the\n extraperitoneal pelvic pre- and perivesical component of the hematoma.\n 2. Unchanged small amount of fluid in the paracolic gutters bilaterally.\n 3. No additional foci of bleeds including no retroperitoneal bleeding.\n\n Dr. was in person informed about the findings in the study by\n Dr. at 3:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2200-02-07 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1123201, "text": ", N. MED FA2 1:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for change in size in hematoma.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with rectus hematoma, elevated inr, blood pressure drop now.\n REASON FOR THIS EXAMINATION:\n please eval for change in size in hematoma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Inrease of the left rectus sheath hematoma.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-08 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1123367, "text": " 6:04 PM\n OTHER EMBO Clip # \n Reason: please eval\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 110\n ********************************* CPT Codes ********************************\n * INITAL 3RD ORDER ABD/PEL/LOWER EXT BILAT A-GRAM *\n * EA ADD'L VESSEL AFTER BASIC A- *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with 70 year old woman with rectus sheath hematoma, actively\n bleeding\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc MON 7:59 AM\n No active extravasation identified. Proximal left inf. epigastric tortuous,\n thus could not selectively catheterize distal enough for safe embolization.\n Right femoral puncture site with angioseal left in place. Pt. left dept\n stable condition.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old female with rectus sheath hematoma and thought to be\n actively bleeding. Continued hematocrit drop, elevated INR due to recent\n anticoagulation for mechanical heart valve.\n\n COMPARISON: None available.\n\n PHYSICIANS: The procedure was performed by Dr. , and Dr. , with\n Dr. the attending interventional radiologist, present and supervising\n the entire procedure.\n\n PROCEDURE: Following explanation of risk, benefits and alternatives of the\n procedure, written informed consent was obtained. A preprocedure timeout was\n performed. The patient was brought to the angiography suite and placed supine\n on the table. The right groin was prepped and draped in the standard sterile\n fashion.\n\n Under fluoroscopic and ultrasound guidance, the right common femoral artery\n was cannulated with the use of a 4 French micropuncture access. A 0.035 wire\n was then advanced into the aorta under fluoroscopy guidance, and the\n micropuncture access kit was exchanged for a 5 French x 11 cm tip\n sheath.\n\n A 4 French Omniflush catheter was advanced into the level of the\n iliac bifurcation and an arteriogram was performed. The\n arteriogram showed patent common, internal and external iliacs\n arteries bilateraly with no signs of active extravazation of\n contrast from distal branches. A C2 catheter was then advanced into the common\n femoral artery on the left, and a run was performed to identify the inferior\n epigastric artery. The origin of the left inferior epigastric artery was\n identified, and a selective run of the left inferior epigastric artery\n (Over)\n\n 6:04 PM\n OTHER EMBO Clip # \n Reason: please eval\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrates a tight and tortuous origin of the left inferior epigastric\n artery. There are no signs of active extravazation of contrast in this\n selective arteriogram. At this point, the microcatheter was advanced into the\n proximal left inferior epigastric artery, but it was not possible to\n superselectively advance the catheter more distally within the inferior\n epigastric artery.\n After communication with Dr. , it was decided not to\n prophylactically embolize, as it was felt the risks would outweigh the\n benefits given only proximal catheterization of inferior epigastric arteries.\n\n After removal of the catheter, the Angio-Seal device was deployed at the\n puncture site due to elevated INR.\n\n During the procedure, the patient's hemodynamic parameters were monitored and\n found to be satisfactory throughout.\n\n IMPRESSION:\n\n 1. No active extravasation seen on arteriogram.\n\n 2. Origin of left inferior epigastric artery tortuous. Attempts to\n perform selective catheterization of this artery were unsuccessful, thus no\n prophylatic embolization was performed.\n\n 3. Angio-Seal device used to puncture site due to elevated INR.\n\n Findings discussed with Dr. (surgery).\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-08 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1123276, "text": " 1:26 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for current bleeding. Please do imaging with\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with known rectus sheath hematoma and enlarging abdomen.\n Please assess for current bleeding.\n REASON FOR THIS EXAMINATION:\n Please assess for current bleeding. Please do imaging with delay.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN WITH CONTRAST.\n\n COMPARISON: .\n\n HISTORY: Rectus sheath hematoma, with enlarging abdomen. Evaluate for\n current bleeding.\n\n TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were\n obtained. IV contrast was administered. Coronal and sagittal reformats were\n performed. Delayed imaging was also obtained.\n\n FINDINGS: There is right basilar atelectasis. There is no pleural or\n pericardial effusion. The left atrium is enlarged. There is a hiatal hernia.\n There is high-density fluid surrounding the liver (2, 13) and (2, 27).\n High-density fluid is also identified along the left flank (2, 51) and right\n flank (2, 60). This is slightly increased when compared to prior exam. The\n spleen contains a subcentimeter hypodensity, which is too small to\n characterize (2, 33). The adrenal glands, pancreas, and liver are\n unremarkable. The gallbladder is distended. The kidneys contain multiple\n hypodense lesions, some of which are too small to characterize and others\n which are incompletely characterized. Small bowel loops are normal in caliber\n and without focal wall thickening. There is a duodenal diverticulum. There is\n no evidence of free air or free fluid. There is vascular calcifications.\n\n Again identified are large rectus sheath abdominal wall hematomas. On delayed\n imaging, there is active extravasation within these hematomas (2B, 110-115)\n likely from the epigastric artery on the left. While the configuration of\n these hematomas have slightly changed, the overall size is similar in\n appearance. Hematoma in the extraperitoneal perivesicular region is also\n identified and not significantly changed (2A, 85). There is adjacent mass\n effect on the bladder, unchanged.\n\n The rectum, sigmoid colon are unremarkable. There is no pelvic or inguinal\n lymphadenopathy.\n\n There is no mesenteric or retroperitoneal lymphadenopathy.\n\n BONE WINDOWS: Degenerative changes are again identified. There are no\n suspicious lytic or sclerotic lesions noted.\n (Over)\n\n 1:26 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for current bleeding. Please do imaging with\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Active extravasation idicating arterial bleeding into left rectus hematoma\n from a branch of the left epigastric artery. Multiple rectus sheath abdominal\n wall hematomas, in a different configuration although not significantly\n changed in size. Hematoma in the extraperitoneal pelvic pre- and perivesical\n space, unchanged.\n 2. Hemoperitoneum adjacent to the liver and in paracolic gutters, slightly\n increased when compared to prior exam.\n 3. Right basilar atelectasis.\n\n Findings were discussed with Dr. via telephone at 2:15 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1123361, "text": " 4:54 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CVL placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CVL plcement\n REASON FOR THIS EXAMINATION:\n CVL placement\n ______________________________________________________________________________\n WET READ: SHfd SAT 6:39 PM\n NO PTX. NEW RIGHT IJ LINE WITH TIP AT PROX SVC. MILDLY DISTEDED PARTIALLY\n IMAGED BOWEL LOOPS.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:19 P.M., ON \n\n HISTORY: Central venous line placement.\n\n IMPRESSION: AP chest compared to most recent prior chest radiograph, , :\n\n Tip of the new right internal jugular line projects over the junction of\n brachiocephalic veins. Right hemidiaphragm is elevated, a new development\n over the past five years. At least moderate intestinal distention is seen in\n the upper abdomen, is not responsible since the left hemidiaphragm is in\n standard placement. Left lung is clear. Patient has had median sternotomy\n and mitral valve replacement. Heart is mildly enlarged, but unchanged and\n there is no pulmonary vascular re-distribution, edema, or appreciable pleural\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1123121, "text": " 2:02 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: worsening colitis? infection?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent admit with undifferentiated colitis now w/\n worsening pain.\n REASON FOR THIS EXAMINATION:\n worsening colitis? infection?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa FRI 4:00 AM\n new large rectus abdominal wall hematomas/fluid collections. can't exclude\n superinfection of these hematomas. also, high density fluid in right paracolic\n gutter, similar. improvement in colitis.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH CONTRAST.\n\n COMPARISON: .\n\n HISTORY: Colitis with worsening pain.\n\n TECHNIQUE: MDCT axially-acquired images through the abdomen and pelvis were\n obtained. IV contrast was administered. Coronal and sagittal reformats were\n performed.\n\n FINDINGS: Ground-glass opacity in the right lung base is again identified.\n There is no pericardial or pleural effusion. There is a median sternotomy and\n valve replacement. There is mild intrahepatic biliary prominence, unchanged.\n The gallbladder is distended. The adrenal glands and pancreas are\n unremarkable. The spleen has illdefined hypodensities, unchanged. The kidneys\n contain multiple hypodense lesions, some of which are too small to\n characterize and others which are incompletely characterized. The small bowel\n loops are normal in caliber. There is no evidence of obstruction. Small\n amount of high-density fluid is identified along the right paracolic gutter\n (2, 58). There is no free air or free fluid. There has been interval\n improvement in wall thickening in loops of small bowel previously identified.\n\n There has been interval development of multiple fluid collections in the\n rectus abdominis muscles. These fluid collections appear to have fluid-fluid\n level with high-density Hounsfield units concerning for hematoma (2, 78). The\n largest fluid collection measures approximately 7.2 x 6.2 cm in the left\n rectus abdominis muscle. Small fluid collection is noted adjacent to this,\n measuring approximately 5.4 x 4.7 cm which has a linear hyperdensity in\n betweent the fluid-fluid level. There is a 2.3 x 2.1 cm hematoma in the right\n rectus abdominis muscle.\n\n CT OF THE PELVIS: The rectum, sigmoid colon are unremarkable. Mass effect of\n the adjacent bladder is noted from the rectus abdominis hematomas. The uterus\n is unchanged in appearance. There is no pelvic or inguinal lymphadenopathy.\n Clips in the right inguinal region are noted.\n (Over)\n\n 2:02 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: worsening colitis? infection?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n\n IMPRESSION:\n 1. Interval development of new bilateral rectus abdominis hematomas.\n Superinfection of these fluid collections cannot be excluded. Linear\n hyperdensity in between fluid-fluid level of one of the hematomas is\n identified and may represent active extravasation. If clinical concern for\n active extravasation exists, repeat delayed imaging or angiography should be\n performed.\n 2. Small amount of high-density fluid in the right paracolic gutter, similar\n in appearance.\n 3. Mild biliary prominence, unchanged.\n 4. Renal and splenic hypodensities, incompletely characterized. Dedicated\n renal/spleen ultrasound is recommended on nonurgent basis.\n 5. Interval improvement in small bowel wall thickening as compared to prior\n exam.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-08 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1123299, "text": " 7:19 AM\n OTHER EMBO Clip # \n Reason: please eval\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * INITAL 3RD ORDER ABD/PEL/LOWER FEE ADJUSTED IN SPECIFIC SITUATION *\n * EXT BILAT A-GRAM FEE ADJUSTED IN SPECIFIC SITUATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with rectus sheath hematoma, actively bleeding\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc TUE 4:25 PM\n No procedure performed because INR was elevated at 3.3. This was discussed\n with Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old female with large rectus sheath hematoma, left greater\n than right, and small amount of active extravasation seen on recent CT scan.\n Please attempt rectus sheath hematoma embolization.\n\n COMPARISON: CT scan earlier the same day and the prior day.\n\n PHYSICIANS: Dr. (resident), Dr. (attending)\n interventional radiologist.\n\n PROCEDURE: Following the explanation of the risks, benefits, and alternatives\n of the procedure, written informed consent was obtained, and a preprocedure\n timeout was performed. The patient was prepped and draped in standard sterile\n fashion.\n\n Just prior to initiating the procedure, an updated INR became available and\n was elevated at 3.3. It was therefore decided not to attempt the procedure,\n as the risks would outweight the benefits. No skin puncture was made, and no\n images were obtained.\n\n IMPRESSION: Procedure postponed until a later time at which the patient's INR\n could be corrected. This was discussed with the patient's team (Dr.\n ) at the time of termination.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-08 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1123300, "text": ", N. MED FA2 7:19 AM\n OTHER EMBO Clip # \n Reason: please eval\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with rectus sheath hematoma, actively bleeding\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n PFI REPORT\n No procedure performed because INR was elevated at 3.3. This was discussed\n with Dr. .\n\n" } ]

[ { "category": "Nursing", "chartdate": "2158-09-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 337674, "text": "56 yr old M admitted with motorcycle crash with ETOH, @ found\n to have temporal bone fx, on CT & to , injuries: 1) sm R\n pneumo 2) fx temp bone with blood in R ear 3) R ptyergoid fx 4) R rib\n fx 5) R scapula fx, spine cleared per trauma\n Alcohol abuse\n Assessment:\n Pt states drinks 1 pint per day & 2-3 beers/day, no signs of\n withdrawal, CIWA scale < 10\n Action:\n Ciwa scale q 4 hrs\n Response:\n No signs of withdrawal, ciwa scale < 10\n Plan:\n Continue to monitor for etoh withdrawal\n Fracture, other\n Assessment:\n To head ct this am, no blood or csf fluid noted to R ear since\n admission to , head ct final read pending, pt to be NPO until head\n ct result back, pt co pain to R scapula fx, #, needs to be reminded\n to use dilaudid pca, neuro vs q 1-2 hrs, no neuro deficits noted, pt\n 3, follows commands, moving all extremites, bedrest maintained\n Action:\n Neuro vs now q 2 hrs, R arm sling when pt oob, assess pain control, may\n start diet / get oob if head ct negative\n Response:\n No c/o pain when @ rest, needs to be reminded to use PCA prior to\n movement/turning, no neuro deficits noted\n Plan:\n Continue to monitor neuro/pain status\n" }, { "category": "Nursing", "chartdate": "2158-09-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 337716, "text": "56 yr old M admitted with motorcycle crash with ETOH, @ found\n to have temporal bone fx, on CT & to , injuries: 1) sm R\n pneumo 2) fx temp bone with blood in R ear 3) R ptyergoid fx 4) R rib\n fx 5) R scapula fx, spine cleared per trauma\n Alcohol abuse\n Assessment:\n Pt states drinks 1 pint per day & 2-3 beers/day, no signs of\n withdrawal, CIWA scale < 10\n Action:\n Ciwa scale q 4 hrs\n Response:\n No signs of withdrawal, ciwa scale < 10\n Plan:\n Continue to monitor for etoh withdrawal\n Fracture, other\n Assessment:\n To head ct this am, no blood or csf fluid noted to R ear since\n admission to , head ct final read pending, pt to be NPO until head\n ct result back, pt co pain to R scapula fx, #, needs to be reminded\n to use dilaudid pca, neuro vs q 1-2 hrs, no neuro deficits noted, pt\n 3, follows commands, moving all extremites, bedrest maintained\n Action:\n Neuro vs now q 2 hrs, R arm sling when pt oob, assess pain control, may\n start diet / get oob if head ct negative\n Response:\n No c/o pain when @ rest, needs to be reminded to use PCA prior to\n movement/turning, no neuro deficits noted\n Plan:\n Continue to monitor neuro/pain status\n ------ Protected Section ------\n Neuro checks have been changed to Q4hrs.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n BLUNT TRAUMA\n Code status:\n Full code\n Height:\n Admission weight:\n 70.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: ETOH, Smoker\n CV-PMH:\n Additional history: NO PMH DOCUMENTED\n Surgery / Procedure and date: RIGHT SCAPULA FX, RIGHT RIB FXS, SMALL\n RIGHT PNEUMOTHORAX, RIGHT TEMPORAL BONE FX, RIGHT ZYGOMA FX WITH AIR ON\n CT. MULTIPLE ABRASIONS TO RIGHT ARM, RIGHT TORSO & BACK. BLOOD FROM\n RIGHT EAR, ? BASILAR SKULL FX.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:61\n Temperature:\n 100\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,873 mL\n 24h total out:\n 1,745 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 01:46 AM\n Potassium:\n 4.0 mEq/L\n 01:46 AM\n Chloride:\n 104 mEq/L\n 01:46 AM\n CO2:\n 28 mEq/L\n 01:46 AM\n BUN:\n 7 mg/dL\n 01:46 AM\n Creatinine:\n 0.6 mg/dL\n 01:46 AM\n Glucose:\n 111 mg/dL\n 01:46 AM\n Hematocrit:\n 33.7 %\n 01:46 AM\n Finger Stick Glucose:\n 114\n 08:00 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: CC6\n Date & time of Transfer: \n ------ Protected Section Addendum Entered By: , RN\n on: 20:59 ------\n" }, { "category": "Nursing", "chartdate": "2158-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 337704, "text": "56 yr old M admitted with motorcycle crash with ETOH, @ found\n to have temporal bone fx, on CT & to , injuries: 1) sm R\n pneumo 2) fx temp bone with blood in R ear 3) R ptyergoid fx 4) R rib\n fx 5) R scapula fx, spine cleared per trauma\n Alcohol abuse\n Assessment:\n Pt states drinks 1 pint per day & 2-3 beers/day, no signs of\n withdrawal, CIWA scale < 10\n Action:\n Ciwa scale q 4 hrs\n Response:\n No signs of withdrawal, ciwa scale < 10\n Plan:\n Continue to monitor for etoh withdrawal\n Fracture, other\n Assessment:\n To head ct this am, no blood or csf fluid noted to R ear since\n admission to , head ct final read pending, pt to be NPO until head\n ct result back, pt co pain to R scapula fx, #, needs to be reminded\n to use dilaudid pca, neuro vs q 1-2 hrs, no neuro deficits noted, pt\n 3, follows commands, moving all extremites, bedrest maintained\n Action:\n Neuro vs now q 2 hrs, R arm sling when pt oob, assess pain control, may\n start diet / get oob if head ct negative\n Response:\n No c/o pain when @ rest, needs to be reminded to use PCA prior to\n movement/turning, no neuro deficits noted\n Plan:\n Continue to monitor neuro/pain status\n Possible sm bleed noted on am head ct scan, trauma to notify neuro to\n get ok to transfer to floor, pt also wanting to go home, sister called\n & spoke with pt, pt now willing to stay in hospital, OOB to chaie with\n 2 assists @ 1845, tol well\n" }, { "category": "Nursing", "chartdate": "2158-09-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 337711, "text": "------ Protected Section------\n Blank note\n ------ Protected Section Error Entered By: , RN\n on: 19:22 ------\n" }, { "category": "Nursing", "chartdate": "2158-09-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 337712, "text": "------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 19:23 ------\n" }, { "category": "Radiology", "chartdate": "2158-09-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1030194, "text": " 8:27 AM\n CT HEAD W/O CONTRAST; CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRASTClip # \n Reason: change from ?\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with Pnemoceph r sidefx temp bone RR Ptyergoid fract\n REASON FOR THIS EXAMINATION:\n change from ?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 56-year-old male with pneumocephalus on prior CT. Evaluate\n for interval change.\n\n COMPARISON: CT facial bones from .\n\n NON-CONTRAST HEAD CT: There is an 11-mm hemorrhagic contusion in the right\n temporal lobe with surrounding edema, unchanged from sinus CT from . No hemorrhage is identified elsewhere. There is no hydrocephalus,\n pneumocephalus or shift of normally midline structures. Note is made of\n diffuse loss of - white matter differentiation, which may be artifactual.\n There are fractures involving the right temporal bone, right anterior\n maxillary wall, right pterygoid plate, and right lamina papyracea, unchanged.\n\n Small amount of right intraorbital emphysema persits. There is extensive\n sinus/ethmoidal mucosal thickening and scattered opacification of the mastoid\n air cells.\n\n IMPRESSION:\n 1. Stable 11-mm right temporal hemorrhagic contusion.\n 2. Resolution of pneumocephlus.\n\n These findings were discussed with Dr. at the time of this\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1030444, "text": ", J. CC6A 8:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with 11 mm tmep lob contusion\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Stable appearance of high attenuation signal within the right temporal\n lobe. However, there is increased area of surrounding vasogenic edema\n consistent with evolution of a hemorrhagic contusion. There is no midline\n shift. There is no uncal herniation. There is an area of hyper-attenuating\n signal in the right frontal convexity which raises the possibility for a\n subdural hematoma. Within the bilateral posterior limb of the internal\n capsule, there are areas of low attenuation which raises the possibility of\n infarction and were not seen on prior study. We would recommend short\n interval followups to further evaluate these changes.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1030127, "text": " 1:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: changes in pneumo\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with rib fx on the RIGHT and small RIGHT apical pneumo\n REASON FOR THIS EXAMINATION:\n changes in pneumo\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS TUE 11:30 AM\n PFI: No definite right pneumothorax, small collection of apical pleural air\n could be obscured by adjacent posterior rib fractures. Stable right apical\n pulmonary contusion. Mild volume overload.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:59 A.M. .\n\n HISTORY: Right rib fractures and small right apical pneumothorax.\n\n IMPRESSION: AP chest compared to at 3:50 p.m.:\n\n Lung volumes are somewhat low, but there is no focal collapse. Right upper\n posterior rib fractures might obscure small right apical pneumothorax. Right\n apical pulmonary contusion, unchanged. Mild volume overload, but no pulmonary\n edema. Heart size normal. No appreciable pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-09-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1030454, "text": " 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: change in pneumo\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with small RIGHT pneumothorax and RIGHT rib fxs\n REASON FOR THIS EXAMINATION:\n change in pneumo\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 4:24 PM\n 1. No pneumothorax.\n\n 2. Rib fractures redemonstrated.\n\n 3. Pleural density is probably a pleural reaction to rib fractures.\n\n 4. Bibasal opacities, probably due to atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 56-year-old man with small right pneumothorax and rib fractures.\n Change in pneumothorax.\n\n COMPARISON: Chest radiograph dated and CT torso dated , .\n\n FINDINGS: There is no radiographic evidence of pneumothorax. Bibasal\n opacities have developed, probably due to atelectasis. There is a right\n pleural soft tissue density, probably represents pleural reaction in response\n to displaced rib fractures. Pulmonary vascularity is not increased.\n\n IMPRESSION:\n 1. No radiographic evidence of pneumothorax.\n\n 2. Slightly displaced right posterior rib fractures redemonstrated.\n\n 3. Right pleural density is likely pleural reaction to the presence of rib\n fractures.\n\n 4. Bibasal opacities are probably due to atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1030455, "text": ", J. CC6A 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: change in pneumo\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with small RIGHT pneumothorax and RIGHT rib fxs\n REASON FOR THIS EXAMINATION:\n change in pneumo\n ______________________________________________________________________________\n PFI REPORT\n 1. No pneumothorax.\n\n 2. Rib fractures redemonstrated.\n\n 3. Pleural density is probably a pleural reaction to rib fractures.\n\n 4. Bibasal opacities, probably due to atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1030443, "text": " 8:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with 11 mm tmep lob contusion\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 12:47 PM\n PFI: Stable appearance of high attenuation signal within the right temporal\n lobe. However, there is increased area of surrounding vasogenic edema\n consistent with evolution of a hemorrhagic contusion. There is no midline\n shift. There is no uncal herniation. There is an area of hyper-attenuating\n signal in the right frontal convexity which raises the possibility for a\n subdural hematoma. Within the bilateral posterior limb of the internal\n capsule, there are areas of low attenuation which raises the possibility of\n infarction and were not seen on prior study. We would recommend short\n interval followups to further evaluate these changes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old man with 11 mm temporal lobe contusion, evaluate for\n interval change.\n\n TECHNIQUE: Head CT, contiguous axial images were obtained through the brain.\n No contrast was administered.\n\n COMPARISON: Head CT from and sinus CT study from and CT head from .\n\n FINDINGS: Within the right temporal lobe, there is an 11-mm x 6 mm area of\n hyperattenuation consistent with an area of hemorrhage. There is significant\n surrounding vasogenic edema which appears to have increased compared to prior\n examination. There is no evidence for midline shift or uncal herniation.\n However, there is slight effacement of the sulci within the right temporal\n lobe compared to prior study.\n\n Along the right frontal convexity, there is an area of heterogeneous signal on\n images (2:12) which could represent a subdural hematoma and was not well\n evaluated on prior studies. There are small areas of questionable low\n attenuation within the posterior limbs of the right and left internal\n capsules, which could represent areas of ischemia and were not well seen on\n prior examination. Within the left frontal lobe, there is an area of low\n attenuation which could represent an area of chronic infarction.\n\n There is a fracture of the right temporal bone as well as the right zygomatic\n arch. Nasal fractures were better characterized on prior CT examination.\n There is extensive mucosal thickening and opacification of bilateral maxillary\n sphenoid, and ethmoid sinuses. The frontal sinuses and mastoid air cells are\n well aerated.\n\n (Over)\n\n 8:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There are no new areas of fracture or no new areas of hemorrhage identified.\n\n IMPRESSION:\n\n 1. Stable appearance of high attenuation area of hemorrhage within the right\n temporal lobe. However, there is significantly more surrounding vasogenic\n edema. There is no shift of midline and there is no evidence for uncal\n herniation. However, there is mild effacement of the right temporal sulci.\n\n 2. Within the right frontal convexity, there is an area of heterogeneous\n signal, which could represent a subdural hematoma and we would recommend short\n interval followup to further evaluate.\n\n 3. Within the right and left posterior limbs of the internal capsule there\n are areas of questionable low attenuation, which could represent areas of\n ischemia and would recommend short interval followup with CT or MRI if patient\n can clinically tolerated to further evaluate.\n\n 4. Extensive fracture through the right temporal bone as well as zygomatic\n arch, which appears stable. There is extensive associated opacification of\n bilateral maxillary, sphenoid, and ethmoid sinuses.\n\n The findings of this result were communicated with Dr. at 12:10 p.m.\n on .\n\n\n" }, { "category": "Radiology", "chartdate": "2158-09-12 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 1030374, "text": " 10:50 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: assess for fracture\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p trauma\n REASON FOR THIS EXAMINATION:\n assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma. Pain.\n\n THREE VIEWS OF THE RIGHT SHOULDER: There are fractures involving at least the\n second through eighth right ribs. Many of these are displaced and involve\n both the posterior and lateral portions of individual ribs. No fracture or\n dislocation is seen involving the shoulder. Probable small right apical PTX.\n Clavicle intact. Overall appearance is little changed from recent exams.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-11 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1030072, "text": " 3:48 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 56-year-old male with trauma.\n\n COMPARISON: None available.\n\n TWO TRAUMA VIEWS OF THE CHEST AND PELVIS: Please note that interpretation is\n somewhat limited due to underlying trauma board. However, there is no supine\n evidence for pneumothorax or unusual abdominal air or fluid collection.\n Discrete visceral line is not seen, but the appearance is suggestive of a\n pneumothorax. Multiple right rib fractures. There is no apparent mediastinal\n widening. The cardiomediastinal contour is normal. The pelvis demonstrates no\n fracture. The proximal femurs demonstrate no fracture. Interpretation of the\n sacrum is somewhat limited by overlying bowel gas.\n\n IMPRESSION: Discrete visceral line is not seen, but the appearance is\n suggestive of a pneumothorax. Multiple right rib fractures.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-11 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1030074, "text": " 4:09 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: acute injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with moped crash\n REASON FOR THIS EXAMINATION:\n acute injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FXKd MON 11:44 PM\n Right temporal bone, pterygoid, maxillary sinus, right medial orbital wall and\n nasal bone fractures are non/minimally displaced. Tiny locule of\n pneumocephalus right temporal fossa.\n WET READ VERSION #1 RSRc MON 11:15 PM\n Right temporal bone, pterygoid, and nasal bone fractures are non/minimally\n displaced.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old male with moped crash. Please evaluate for acute\n injury.\n\n COMPARISON: Outside hospital head CT from the same day.\n\n TECHNIQUE: Axial imaging was performed through the facial bones. Coronal\n reformations were provided.\n\n CT FACIAL BONES: There is a minimally displaced right mastoid fracture\n extending into the right squamosal temporal bone (2:61), and an adjacent small\n locule of pneumocephalus. There is a nondisplaced horizontal fracture of the\n right pterygoid plate (2:70). There is a minimally displaced nasal bone\n fracture (2:26). There are additional fractures throught the anterior and\n lateral right maxillary sinus, and right medial lamina paprycea, all\n non/minimally displaced. There is mucosal thickening of the ethmoid and\n maxillary sinuses bilaterally, consistent with chronic sinus disease. No\n large hematoma is appreciated.\n\n IMPRESSION:\n\n 1. Right temporal bone fracture.\n 2. Small locule of adjacent pneumocephalus.\n 3. Right pterygoid bone fracture.\n 4. Minimally displaced nasal bone fracture.\n 5. Fractures throught the right medial orbital wall and right maxillary\n sinus.\n\n These findings were posted to ED dashboard at 11 p.m. on , but were\n discussed at the time the patient was brought to the emergency department with\n the team caring for the patient (Dr. ).\n (Over)\n\n 4:09 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: acute injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2158-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1030128, "text": ", J. TSICU 1:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: changes in pneumo\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with rib fx on the RIGHT and small RIGHT apical pneumo\n REASON FOR THIS EXAMINATION:\n changes in pneumo\n ______________________________________________________________________________\n PFI REPORT\n PFI: No definite right pneumothorax, small collection of apical pleural air\n could be obscured by adjacent posterior rib fractures. Stable right apical\n pulmonary contusion. Mild volume overload.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-09-11 00:00:00.000", "description": "Report", "row_id": 1664840, "text": "1845\npt arrived from , s/p trauma transfer motorcycle accident. right scapula fx, right rib fx, small right pnumo, right temporal bone fx, right zygoma fx, multi abrasions. pt placed on moniotr VSS, sat 98% on 2 l, lung sounds clear. A&O X3. c/o pain 1mg dilaudid given. pt refused to turn side to side and was left on back. pupils 1mm reactive, sclara red, grasps =, MAE. plan of care discussed with pt. pt states no allergies or medical history except has been in rehab for ETOH, and currently drinks 1 pt of hard alcohol per day.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-12 00:00:00.000", "description": "Report", "row_id": 1664841, "text": "Events: Pt admitted @ 1900 . Pt refusing to turn throughout the shift. labs drawn and lytes repleted beginning of shift. PCA dilaudid started. Pt on CIWA scale as he admits to drinking pint of hard etoh/day and 2-3 beers/day. Ativan given 0.5 mg ivp X1 with good effect CIWA scale>10=11. Neuro checks changed from Q2hrs to Q1hr. No new bleeding noted in right ear and no CSF noted either. Pt refusing to turn on right side and refusing heparin shots- Dr. aware. LS wheezy- Chest x ray obtained- ? worsening pneumo and placed on NRB also Started on Albuterol MDI- with improvement to LS.\n\nROS:\n\nNeuro: Q1hr neuro checks. Pt A/O X3. Follows all commands. MAE's with right upper arm weakness and only able to move that arm on the bed comminuted scapula fracture- pt refusing to wear sling at this time even though explained by this nurse that it would probably feel better if supported by the sling. PERRLA 2mm and briskly reactive bilaterally. Dilaudid PCA 0.12/6/1.2 using appropriately C/O right shoulder pain..CIWA scale for etoh w/d. At 0400 pt noted to be anxious, yelling that he wanted to get up and OOB and taking his O2 off. Also noted to have beads of sweat on his head. No tremor, no nausea- given 0.5mg ativan for CIWA scale of 11 with good relief.\n\nCVS: NSR HR 70-80's. SBP 120-150's. A febrile. LR @75. p boots and refsuing heparin SQ. Lytes repleted\n\nResp: LS wheezy-clear upper and diminished lower. Pt refusing to CBD. Albuterol MDI given X1 with good effect. Chest x ray done this am and ? worsening pneumo right side- MD placed on NRB to help with pneumo.\n\nGI: NPO, given pills with a little bit of H2O ok per Dr. . +BS. H2B for prophylaxsis.\n\nGU: draining adeqaute amounts of clear yellow urine.\n\nEndo: no cvg needed per RISS\n\nID: no abx ordered.\n\nSocial: sister called for update will be in tomorrow to visit.\n\nPlan:\nContinue to monitor Q2hr neuro checks and monitor for blood from right ear. Advance diet. Increase activity as tolerated. ? epidural- pt was refusing earlier for adequate pain control. ? transfer to the floor.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-12 00:00:00.000", "description": "Report", "row_id": 1664842, "text": "addendum\nPt was also refusing to be washed and refusing to be turned to right side also refusing skin care/back care.\n\nSkin: see carevue for assessment-mutliple abrasions noted to right arm and back. Cleaned with NS and covered with bacitracin\n" } ]

[ { "category": "Nursing/other", "chartdate": "2191-01-31 00:00:00.000", "description": "Report", "row_id": 1594972, "text": " 04 TO 07\n A/O MALE TO SICU FROM ER FOR ABD BLEED LIVER CA NO PAIN OR DISCOMFORT IN GOOD SPIRITS\n RESP CLEAR NO SOB ROOM AIR SAO2 99 ON 2 L NP S1S2 DISTANT SL NVD FULL LIVER 2 BELOW\n GI POS B/S STOOLING EATING POORLY FOR TWO WEEKS\n POOR GATE PALE IN COLOR TWO UNITS PC FOLEY CATH\n PLAN SUPPORTIVE CARE MONITOR H/H POSSIBLE ANGIO IF BLEEDING REMAINS\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-01-31 00:00:00.000", "description": "Report", "row_id": 1594973, "text": "Nursing Note 7a-7p:\nNursing assessment:\n\nNeuro: pt is alert and orientated to person place and time. MOves all extremities.\n\nResp: 2Liters nasal cannula sats 97-98%. Lungs clear, diminished at bases\n\nCV/GU: BP 100-130 for shift. Gradually increasing throughout day. Voiding clear yellow urine in foley cath. 1 unit PRBC's today HCT up to 31.\n\nGI: BS present. NPO for today. Pt states he is hungry and passing flatus. Abdomen softly distended.\n\nPlan: monitor hct q 4 hours. npo. ivf at 75cc/hr. monitor bp. continue with basic nuring care.\n" }, { "category": "Nursing/other", "chartdate": "2191-02-01 00:00:00.000", "description": "Report", "row_id": 1594974, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n\nNeuro: Pt easily arousable by voice. Ox2-3; sometimes confused about year and time of day. Pt stated that it was \",\" and thought that it was day time; easily re-oriented. Moves all extremities. Follows commands. Clear speech. PERRLA. Pt denies any pain. Pt remains full code at this time; no signed DNR/DNI form in chart. Dr. will discuss code status w/ Dr. in AM.\n\nCV: Tmax 100 (down to 99.8 at 0400). HR 70-80s (NSR). NBP 120-150s/ 40-70s. Trace bilat pedal edema noted. DP/PT pulses weakly palpable. IVF: NS @ 75cc/hr infusing. Pt denies chest pain. Q4hr Hct discontinued at 0300 per Dr. d/t Hct stable (32). Magnesium 1.7 (replaced).\n\nPulm: Lungs sound CTA, diminished at bases. O2 sat 92% on RA when asleep; placed on 2LNC (O2 sat >/= 95%). Non-productive cough at times. No c/o SOB; no apparent distress.\n\nGI: Abdomen softly distended w/ +BS. Pt tolerating regular diet. No N/V overnight. FS q6hr w/ RISS (no insulin needed this shift).\n\nGU: Foley intact w/ yellow urine (+sediments). UO >/= 30cc/hr.\n\nSocial: wife called x1 and updated by RN. wife will visit in AM.\n\nPlan: Continue to monitor VS, I's and O's, neuro status. Follow up w/ code status in AM. ? transfer to oncology floor today. Update family and pt w/ plan of care. Continue ICU care and treatments.\n" }, { "category": "Radiology", "chartdate": "2191-02-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 856721, "text": " 8:56 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrates\n Admitting Diagnosis: LIVER HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with HCC, liver hemorrhage now with SOB\n REASON FOR THIS EXAMINATION:\n r/o infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n Two view chest .\n\n COMPARISON: .\n\n INDICATION: Shortness of breath.\n\n FINDINGS:\n\n Examination is technically limited due to low lung volumes and lordotic\n projection. Allowing for this factor, cardiac and mediastinal contours are\n stable. There has been development of a small left pleural effusion. Within\n the lungs, there are no areas of consolidation. Diffuse haziness is noted in\n the imaged portion of the upper abdomen, and there is marked gastric\n distension with a prominent air fluid level on the lateral view.\n\n IMPRESSION:\n\n 1) New small left pleural effusion.\n\n 2) Findings suggestive of ascites in the abdomen.\n\n 3) Marked gastric distention.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-01-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 856444, "text": " 11:50 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: assess for interval change, source of pain\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with R lobe HCC on chemo, h/o resolved portal v thrombosis,\n tender upper quadrants\n REASON FOR THIS EXAMINATION:\n assess for interval change, source of pain\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg MON 12:39 AM\n Hematoma inferior to right lobe of liver and diffuse increase in density of\n ascites compared to prior consistent with intraperitoneal hemorrhage most\n likely from large right lobe HCC.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Hepatocellular carcinoma on chemotherapy with history of portal\n vein thrombosis and right upper quadrant tenderness. Evaluate for intra-\n abdominal pathology.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis without intravenous contrast initially. Following initial findings,\n a multiphasic CT of the liver was performed using axial MDCT images through\n the abdomen in the early arterial and portal venous phases, followed by\n delayed axial MDCT images from the lung bases to the pubic symphysis.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the rapid\n rate of bolus injection acquired to this examination.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There are\n atelectatic changes at the lung bases bilaterally, right greater than left.\n The visualized portions of the heart and pericardium demonstrate coronary\n arterial calcifications and appear otherwise unremarkable. The initial\n noncontrast images demonstrate a dense, heterogeneous fluid collection\n lateral and inferior to the right lobe of the liver, consistent with hematoma.\n In addition, there is diffuse increase in the density of the patient's ascites\n located elsewhere in the abdomen, and interval increase in the quantity of\n dense ascites consistent with hemoperitoneum. Multiphasic CT of the liver\n again demonstrates a large heterogeneous mass within the right lobe of the\n liver consistent with the patient's known hepatocellular carcinoma. This\n measures approximately 12 x 18 cm and appears increased in size from the\n previous examination. Irregularity of the tumor margin along its right\n lateral aspect could represent rupture. Additional areas of perfusion\n abnormality are again seen within the right and left lobes are consistent\n with additional satellite lesions as previously described. There is no\n evidence of active extravasation of contrast on the early phase images, and no\n evidence of increasing density of the hematoma on delayed images to suggest\n active extravasation. There is stable splenomegaly. The pancreas, probable\n (Over)\n\n 11:50 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: assess for interval change, source of pain\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n posterior gastric diverticulum, and adrenal glands appear unchanged. There is\n symmetric nephrograms bilaterally without evidence of hydronephrosis in either\n kidney. The appearance of the kidneys is unchanged, with parapelvic and\n cortical cyst. The large and small bowel loops are normal in caliber, with no\n evidence of abnormally dilated loops. No oral contrast is present. There is\n no free air within the abdomen. The aorta is normal in caliber with mural\n calcifications consistent with atheromatous disease. No evidence of\n dissection is identified on the arterial phase images.\n\n The previously described filling defect in the portal vein is again seen\n consistent with portal vein thrombus, probably representing tumor thrombus.\n The gallbladder is nondistended. There is a marked amount of pericholecystic\n fluid, a nonspecific findings that could relate to the patient's liver disease\n or to hypoalbuminemia. The common bile duct is nondilated.\n\n CT OF THE PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST: There is interval\n increase in the amount of intermediate density ascites within the abdomen. The\n bladder, distal ureters, rectum and sigmoid colon, prostate and seminal\n vesicles appear unremarkable. There is no pathologic appearing pelvic or\n inguinal lymphadenopathy.\n\n BONE WINDOWS: Bone windows demonstrate degenerative changes without evidence\n of suspicious lytic or sclerotic osseous lesion.\n\n IMPRESSION:\n\n 1. Hemorrhage from right lobe hepatocellular carcinoma, with findings\n suggestive of tumor rupture. Interval development of perihepatic hematoma and\n diffuse increase in density and quantity of abdominal ascites consistent with\n hemoperitoneum. No definite evidence of active extravasation.\n\n 2. Portal vein thrombosis, unchanged, likely representing tumor thrombus.\n\n 3. Pericholecystic fluid likely relates to hepatic disease and\n hypoalbuminemia. Clinical correlation is recommended.\n\n 4. No bowel obstruction. No evidence of aortic dissection.\n\n\n These results were discussed immediately with Dr. of the\n emergency department at the time of interpretation.\n\n\n (Over)\n\n 11:50 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: assess for interval change, source of pain\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2191-02-02 00:00:00.000", "description": "Report", "row_id": 159669, "text": "Sinus rhythm\nLong QTc interval - is nonspecific but clinical correlation is suggested for\npossible metabolic/drug effect\nSince previous tracing of , Q-Tc interval appears longer but may be no\nsignificant change\n\n" }, { "category": "ECG", "chartdate": "2191-01-30 00:00:00.000", "description": "Report", "row_id": 159670, "text": "Sinus bradycardia. Low limb lead voltage. Compared to the previous tracing\nof no change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2126-12-27 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 999118, "text": " 9:05 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for continued bleeding, increasing shift, hy\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with rebleed into SAH on coumadin for L proximal DVT. This\n study should be done about 9:00 a.m. .\n REASON FOR THIS EXAMINATION:\n Please evaluate for continued bleeding, increasing shift, hydrocephalus, or any\n other acute processes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST, \n\n HISTORY: Rebleeding into subdural hematoma.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT scan performed earlier on .\n\n FINDINGS: There have been no significant changes since the prior study.\n Again identified are bilateral chronic-appearing subdural hematomas with fresh\n blood in the left frontal collection. Left to right midline shift persists.\n There is no evidence of new hemorrhage in the interval from midnight until\n 9:00 a.m.\n\n CONCLUSION: No change since the head CT performed earlier on . Again seen are bilateral subdural hematomas that appear chronic with\n superimposed acute hemorrhage on the left. Left hemispheric mass effect and\n left to right shift persist, unchanged.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2126-12-28 00:00:00.000", "description": "Report", "row_id": 1655923, "text": "Nursing Progress Note 7pm-7am\n\nROS: See carevue for exact data\n\nN: Pt alert and oriented x3. Pleasant female. MAE's, follows all commands. No confusion noted. Q1 hr neuro checks. Good equal strength x all ext's. Pupils equal and reactive 3mm bilaterally and brisk. ATC dilantin. No sz activity. Denies any pain, denies HA.\n\nCV: SR, will brady to 50's while sleeping. Occasional PAC's. BP normaltensive. Palp pulses. No venodynnes due to s/p DVT. IVF's hl'd.\n\nResp: LSCTA, sats 99% on RA. Denies SOB.\n\nGI: Abd soft, positive BS. Good Po's. @ BM overnoc. Swallows pills well.\n\nGu: u/o adeq, using commode. Clr yellow urine.\n\nSkin: Intact, old healed crani site.\n\nEndo: Bld sugars initially 180's then down to 120-130's. Insulin per sliding scale.\n\nLytes: No repletion needed.\n\nAccess: PIV x2\n\nID: tmax 99.0\n\nPlan: Transfer to stepdown bed today, ? evac of blood on monday. Cont to monitor q1 hr neuro checks, monitor for pain, HA. Maintain adeq control of BP. pt to cough and deep breath. OOB with assist to commode. Cont with current plan of care, emotional support provided.\n" }, { "category": "Nursing/other", "chartdate": "2126-12-27 00:00:00.000", "description": "Report", "row_id": 1655921, "text": "Admission and ROS\nS/P bilateral SDH, evacuation, crani r/t fall. D/C to , returned to for LLE DVT. Started on coumadin after stable CT, then returned to . Returns to w/ new onset \"clumsiness\" w/ eating and some dysarthria. Ct shows new bleed inside of old bleed w/ increased right shift. Neuro exam has been completely normal since admission.\n\nNeuro: AAO x 3, unsure of exact date; follows commands consistently. Moves all extremities w/ equal strength, no drift. PERRLA, no nystagmus. Denies any pain, visual disturbances or anxiety. Calm and cooperative. Dilantin level pending.\n\nCV: SB to low 40's, no ectopy. SBP 120's-140's. Pulses strongly palpable, no edema. Pboots DVT prophy.\n\nPulm: RA sats 99-100%. BS essentially CTAb, dry cough.\n\nGI: abd soft, non-tender; active BS. No stool. NPO except sip w/ am meds. PPI prophy\n\nGU: voids clear urine on bedpan. NS @ 75cc/hr.\n\nEndo: RISS, adequate.\n\nID: afebrile. No antibx.\n\nHeme: 2 units FFP tx, repeat labs pending.\n\nP: Neuro exam q 1 hr. repeat head CT later this am. Repeat labs to follow INR, goal<1.5. ? IVC when INR stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2126-12-27 00:00:00.000", "description": "Report", "row_id": 1655922, "text": "NPN: Review of Systems\nNeuro: Pt drowsy, easily wakes to voice. Has said and that she is at , the year is , and has told me her name. Pt has been conversant. Calm and pleasant. Using call light for assistance. PERRL. Able to MAES. OOB to commode w/ one assist. Denies haedache, nausea. No seizure activity observed. Continues on Dilantin as ordered. Repeat head CT completed.\n\nResp: Breathing unlabored. BS are CTA bilaterally. Sao2 on room air=98-100%.\n\nCV: HR 48-50s. No ectopy. K+=4.1 Skin warm/ dry. Palpable DP pulses bilaterally. Afebrile w/ oral temp=98.6\n\nHeme: HCT=33.4, WBC=4.7, and PLts=284. INR=1.0 from 1.8, after 2units of FFP.\n\nGI: Pt c/o being hungry. Abdomen is soft/ nondistended. (+) bowel sounds. NS infusing at 75cc/hr. Fingerstick glucose= 110 and 109.\n\nGU: Pt has voided using commode. BUN/Cr=15/0.5.\n\nSkin: Intact.\n\nSocial: Heathcare proxy, , called. Updated on Pt's condition. Pt's primary physician, . has also called and spoke w/ Dr..\n\nA:Pt has been stable throughout the shift. No change in neuro assessment.\n\nP: Pt may begin to have regular diet and OOB as tolerated. Anticipate surgery Monday. Per Dr. , am CT revealed increase in size of hematoma.\n\n\n\n" }, { "category": "ECG", "chartdate": "2126-12-26 00:00:00.000", "description": "Report", "row_id": 299154, "text": "Sinus bradycardia. Otherwise, no other significant diagnostic abnormality.\nCompared to the previous tracing of there is no significant diagnostic\nchange.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2173-11-19 00:00:00.000", "description": "Report", "row_id": 1583811, "text": "NURSING ADMISSION NOTE\n\nPT IS 88YO FEMALE, PMH HTN, DEMENTIA, DEPRESSION, SEVERE COPD(STEROID DEPENDENT IN PAST) PEPTIC ULCER DISEASE S/P GASTRECTOMY, NIDDM, GERD, AND RECENT HX RAPID AFIB, WITH CARDIOVERSION , HYPONATREMIA\n\nAT LUNCH TODAY PT C/O THAT SHE WAS NOT FEELING WELL, AT @ 2PM THIS AFTERNOON PT BECAME AND UNAROUSABLE, O2 SAT 45% ON RA, PT PLACED ON 4LNC O2 RAISED TO 80-90'S, BP AT THAT TIME WAS 140/60, PT THEN SENT TO ER, ON ARRIVAL TO ER DECREASED MS, RESP 30'S ABG 7.16/132/386, CXR SHOWED RLL INFILTRATE AND EFFUSION, PT PLACED ON MASK VENTILATION REPEAT ABG 7.23/100/102, WHILE IN ER PT HAD 2 EPISODES OF RAPID AFIB TO 120'S, BP DROPPED TO 65, 250CC FLUID BOLUS GIVEN, PT THEN CONVERTED TO SR, PT ADM TO MICU ON MASK VENTILATION, ABG THEN 7.33/70/92, PT THEN PLACED ON 3LNC, POX 93-96%, PT STARTED ON ANTIBIOTICS\n\n\n SON IN , HE STATES PT IS DNR/DNI\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-19 00:00:00.000", "description": "Report", "row_id": 1583812, "text": "NURSING NOTE\n\nPT AWAKE AND ALERT MOST OF THE NIGHT, SPEAKS ONLY RUSSIAN, DIFFICULT TO UNDERSTAND, VSS, AFEBRILE, BP 100/35-119/47, HR 94-107, PT L PERIPH IV OUT, REPLACED WITH 18GAUGE HL, LUNGS BS DECREASED, O2 3LNC POX 98-99% THIS AM, FOLEY CATH IN PLACE DRAINING @ 20CC/HR, IV ANTIB GIVEN AS ORDERED, BLD CX AND URINE CX SENT FROM ER LAST PM,SKIN INTACT, PT TURNED AND REPOSIT ALTHOUGH PT FAVORING R SIDE, PT NOW SLEEPING, SEE CAREVUE FOR FULL ASSESSMENTS\n" }, { "category": "Echo", "chartdate": "2173-11-24 00:00:00.000", "description": "Report", "row_id": 70178, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function. S/p cardioversion.\nBP (mm Hg): 128/70\nStatus: Inpatient\nDate/Time: at 10:15\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: There is lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Overall\nleft ventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Physiologic mitral regurgitation is seen (within\nnormal limits).\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitaton. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets are mildly thickened. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2173-11-18 00:00:00.000", "description": "Report", "row_id": 151468, "text": "Sinus tachycardia. Left atrial abnormality. Non-specific ST-T wave\nabnormalities in leads I, aVL and V5-V6. Compared to the previous tracing\nof the rate is faster.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 745911, "text": " 2:51 PM\n CHEST (PA & LAT) Clip # \n Reason: re-eval pleural effusion. r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman p/w MS, O2sat. Pt w/h/o COPD (chr CO2 retainer), HTN,\n rapid AF+cardioversion. CxR w/unchanged pleural effusions, but ?congestive\n failure. Pls re-eval.\n REASON FOR THIS EXAMINATION:\n re-eval pleural effusion. r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Re-evaluate pleural effusion, rule out CHF.\n\n PA AND LATERAL CHEST RADIOGRAPHS DATED : Compared to portable AP chest\n radiograph dated . There are bilateral pleural effusions. The right\n pleural effusion is moderate in size; however, it has an unusual\n configuration. This may indicate loculation. The plerual effusion on the\n left is small to moderate in size and has increased compared to the prior\n study. There is improved aeration of the right lung compared to the prior\n study. The left lung is unchanged. There is slight upper zone redistribution\n in the pulmonary vascularity, and it is difficult to compare the cardiac\n silhouette secondary to the pleural effusions. The mediastinum appears\n normal.\n\n IMPRESSION:\n 1. Moderate-sized right pleural effusion that may be loculated. Recommend a\n right lateral decubitus film to assess for layering.\n\n 2. Left pleural effusion that has increased in size.\n\n 3. Upper zone redistribution of the pulmonary vascularity but no frank\n pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 745675, "text": " 6:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: sob, uresponsive w low o2 sat, r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with\n REASON FOR THIS EXAMINATION:\n sob, uresponsive w low o2 sat, r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n A single portable view of the chest compared to the prior study dated .\n The heart is persistently enlarged. The mediastinal structures are\n unremarkable. There is a new right basilar opacity which obscures the\n hemidiaphragm and right heart border. This is consistent with a pleural\n effusion. An underlying infiltrate and/or atelectasis cannot be excluded.\n There is no pneumothorax. There is also a linear density at the left base\n suggesting subsegmental atelectasis. The remaining lungs are unremarkable.\n The osseous structures are intact.\n\n IMPRESSION: New right-sided pleural effusion with possible associated\n atelectasis and/or infiltrate. There is subsegmental atelectasis at the left\n base.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-11-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 745847, "text": " 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: An 88 woman with resp distress, now lethargic, not doing wel\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with as above\n REASON FOR THIS EXAMINATION:\n An 88 woman with resp distress, now lethargic, not doing well.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 10:31AM \n\n HISTORY: Respiratory distress, lethargy.\n\n The heart is enlarged. There are bilateral pleural effusions, greater in the\n right chest then the left. Underlying, infiltrates cannot be excluded. There\n is pulmonary venous cephalization.\n\n IMPRESSION: Congestive failure. Infiltrates at the lung bases cannot be\n excluded.\n\n The appearance of the chest deteriorated since .\n\n" } ]

[ { "category": "Echo", "chartdate": "2124-06-30 00:00:00.000", "description": "Report", "row_id": 90883, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary hypertension. Right ventricular function. Valvular heart disease\nHeight: (in) 72\nWeight (lb): 243\nBSA (m2): 2.32 m2\nBP (mm Hg): 103/53\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 10:25\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: Moderately dilated RA.\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%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity.\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.\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. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Moderate to severe [3+] TR. Moderate PA systolic\nhypertension. Given severity of TR, PASP may be underestimated due to elevated\nRA pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is normal in size. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is normal (LVEF 65%). The right ventricular cavity is dilated The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate to severe\n[3+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. [In the setting of at least moderate to severe\ntricuspid regurgitation, the estimated pulmonary artery systolic pressure may\nbe underestimated due to a very high right atrial pressure.] There is no\npericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2124-06-26 00:00:00.000", "description": "Report", "row_id": 90884, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath. Hypoxemia\nHeight: (in) 72\nWeight (lb): 400\nBSA (m2): 2.86 m2\nBP (mm Hg): 126/68\nHR (bpm): 106\nStatus: Inpatient\nDate/Time: at 14:00\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\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Estimated cardiac index is high\n(>4.0L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate PA systolic\nhypertension.\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. Suboptimal\nimage quality - body habitus. Echocardiographic results were reviewed by\ntelephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The estimated cardiac index is high (>4.0L/min/m2). The right\nventricular cavity is mildly dilated with normal free wall contractility. The\nascending aorta is mildly dilated. The aortic valve leaflets (?#) appear\nstructurally normal with good leaflet excursion. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are not\nwell seen. Physiologic mitral regurgitation is seen (within normal limits).\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global and regional systolic function. Mild right\nventricular cavity enlargement. Pulmonary artery hypertension. Dilated\nascending aorta.\nIs there a history to suggest pulmonary embolism or sleep apnea?\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": "2124-06-29 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1246074, "text": " 1:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pulm edema\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with worsening interstitial infiltrates\n REASON FOR THIS EXAMINATION:\n pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with worsening interstitial infiltrates/pulmonary\n edema, assess for interval change.\n\n COMPARISONS: Chest radiograph from earlier today.\n\n FINDINGS: The diffuse interstitial opacities, reflecting a combination of\n edema and potential infectious process, appear improved from the radiograph\n from earlier today, though remains slightly worsened from . Cardiac\n atelectasis is unchanged. No large pleural effusions are identified. Left\n PICC is not well assessed on this radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2124-06-26 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1245678, "text": " 2:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with acute desat in oxygen\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with acute desaturation, assess for interval\n change.\n\n COMPARISONS: , from three hours previous.\n\n FINDINGS: Left PICC terminates in the left brachiocephalic vein slightly\n withdrawn from the previous examination with unchanged moderate-to-severe\n pulmonary edema. Bilateral pleural effusions are tiny if any with no\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2124-06-26 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1245703, "text": " 7:13 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Eval PICC LINE\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent PICC line placement.\n REASON FOR THIS EXAMINATION:\n Eval PICC LINE\n ______________________________________________________________________________\n WET READ: NATg MON 7:53 PM\n Asymmetric pulmonary edema slightly improved. Small bilateral effusion. LUE\n picc tip at cavoatrial junction.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recent PICC line placement, reevaluation.\n\n FINDINGS: The left PICC line has been advanced. The tip of the line projects\n over the lower SVC. The course of the line is unremarkable. The pre-existing\n bilateral, right predominant central pulmonary edema has decreased in extent\n and severity. The size of the cardiac silhouette is unchanged. No pleural\n effusions can be identified.\n\n\n" }, { "category": "ECG", "chartdate": "2124-07-03 00:00:00.000", "description": "Report", "row_id": 231571, "text": "Sinus rhythm. Delayed R wave progression is likely a normal variant.\nNon-specific septal T wave flattening. Possible inferior wall myocardial\ninfarction of indeterminate age. Compared to the previous tracing of \nthe Q waves in leads III and aVF are slightly more prominent.\n\n\n" }, { "category": "ECG", "chartdate": "2124-07-02 00:00:00.000", "description": "Report", "row_id": 231572, "text": "Sinus rhythm. Delayed R wave progression, may be a normal variant.\nNon-specific ST-T wave changes. Compared to the previous tracing of no\nsignificant change.\n\n\n" }, { "category": "ECG", "chartdate": "2124-06-22 00:00:00.000", "description": "Report", "row_id": 231797, "text": "Artifact is present. Sinus tachycardia. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2124-06-28 00:00:00.000", "description": "Report", "row_id": 231794, "text": "Sinus tachycardia. Low limb lead voltage. Delayed precordial R wave\ntransition. Diffuse non-specific ST-T wave flattening. Compared to the\nprevious tracing of atrial ectopy is no longer recorded. Otherwise, no\ndiagnostic interim change.\n\n\n" }, { "category": "ECG", "chartdate": "2124-06-25 00:00:00.000", "description": "Report", "row_id": 231795, "text": "Sinus tachycardia with atrial premature contractions. Poor R wave progression.\nQuestion clockwise rotation. Question lead placement. Cannot rule out prior\nanterior wall myocardial infarction. Diffuse non-specific ST-T wave\nabnormalities. Compared to the previous tracing of poor R wave\nprogression is somewhat more marked, question lead placement. Clinical\ncorrelation and repeat tracing are suggested.\n\n\n" }, { "category": "ECG", "chartdate": "2124-06-22 00:00:00.000", "description": "Report", "row_id": 231796, "text": "Artifact is present. Sinus tachycardia. Non-specific ST-T wave changes.\nCompared to tracing #1 there is no significant change.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2128-08-24 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 974865, "text": " 1:12 AM\n HAND (AP, LAT & OBLIQUE) LEFT; WRIST(3 + VIEWS) LEFT Clip # \n Reason: acute fracture\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 yo male with MVC\n REASON FOR THIS EXAMINATION:\n acute fracture\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hand three views .\n\n HISTORY: 40-year-old man with motor vehicle accident.\n\n FINDINGS: There are no previous studies available for direct comparison.\n\n No acute fractures or dislocations are seen. There is normal osseous\n mineralization.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-08-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 974852, "text": " 9:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for head, facial trauma. Thanks.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with obvious facial trauma s/p unhelmeted MCC. +LOC. repetitive\n questioning. Confused.\n REASON FOR THIS EXAMINATION:\n please eval for head, facial trauma. Thanks.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 10:51 PM\n Multiple small foci of subarachnoid hemorrhage of both frontal lobes, left\n temporal lobe and along right suprasellar cistern and interhemispheric\n fissure. 16 x 9 mm oval shaped area of right temporal hyperdensity probably\n parenchymal contusion. No fracture or epidural hematoma. Extensive soft\n tissue swelling of left face/left frontal and right parietal regions. MRI may\n be helpful for further evaluation.\n WET READ VERSION #1 MPtb MON 10:18 PM\n Multiple small foci of subarachnoid hemorrhage of both frontal lobes, left\n temporal lobe and along right suprasellar cistern and interhemispheric\n fissure. 16 x 9 mm oval shaped area of right temporal hyperdensity probably\n parenchymal contusion. No fracture or epidural hematoma. Extensive soft\n tissue swelling of left face/left frontal and right parietal regions. MRI may\n be helpful for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old male after unhelmeted motorcycle collision with obvious\n facial trauma and loss of consciousness with concern for intracranial\n hemorrhage.\n\n COMPARISON: No prior study available.\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: Multiple small foci of subarachnoid hemorrhage are noted in both\n frontal lobes, left temporal lobe, along the interhemispheric fissure, and\n along the right side of the suprasellar cistern. A 16 x 9 mm circumscribed\n oval-shaped focus of hyperdensity in the right temporal lobe is more likely a\n hemorrhageic parenchymal contusion. No fracture or evidence of epidural\n hematoma is identified. There is extensive soft tissue swelling of the left\n face and left frontal scalp as well as smaller areas of scalp swelling of the\n biparietal regions. The ventricles and sulci are symmetric. There is no\n evidence of hydrocephalus or major vascular territorial infarction. There is\n no shift of normally midline structures or significant mass effect. The\n visualized paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Multiple small scattered foci of subarachnoid hemorrhage in both frontal\n lobes, left temporal lobe, and along the interhemispheric fissure and right\n suprasellar cistern.\n 2. Small parenchymal hemmorhagic contusion of the right temporal lobe.\n 3. Soft tissue hematoma of the left face, left frontal and biparietal scalp.\n (Over)\n\n 9:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for head, facial trauma. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n ER dashboard wet read placed at 10:15 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2128-08-23 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 974853, "text": " 9:37 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please eval for facial fx. thanks.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with obvious facial trauma s/p unhelmeted MCC. +LOC. repetitive\n questioning. Confused.\n REASON FOR THIS EXAMINATION:\n please eval for facial fx. thanks.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SGA TUE 12:11 AM\n nondisplaced fracture of posterior superior left orbital wall, adjacent to SAH\n seen on head ct, no other fractures identified\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Obvious facial trauma, status post unhelmeted motorcycle\n collision, loss of consciousness, confused.\n\n COMPARISONS: Head CT performed same day.\n\n TECHNIQUE: Axial non-contrast images were obtained through the facial bones.\n\n CT SINUS/FACIAL BONES: There is a minimally displaced fracture of the\n superior orbital wall posteriorly within the left orbit (series 700B, image\n 92). There is minimal displacement of the fracture fragments into the orbit.\n However, no intraconal abnormality is identified and the orbits appear intact\n otherwise. The globes appear intact. There is an adjacent\n subarachnoid hemorrhage seen on recent head CT. Otherwise, no fractures are\n identified. The paranasal sinuses are well aerated with minimal mucosal\n thickening within the right maxillary sinus. Soft tissue hematoma of the left\n face and left frontal scalp are again identified.\n\n IMPRESSION: Nondisplaced fracture involving the posterior superior left\n orbital wall, adjacent to subarachnoid hemorrhage seen on recent head CT.\n Otherwise, no fractures identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-08-23 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 974854, "text": " 9:38 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FACIAL TRAUMA.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with obvious facial trauma s/p unhelmeted MCC. +LOC. repetitive\n questioning. Confused.\n REASON FOR THIS EXAMINATION:\n please eval for fx or malalignment.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man with obvious facial trauma, status post\n unhelmeted MCC. Positive loss of consciousness. Evaluate for fracture or\n malalignment.\n\n CT C-SPINE WITHOUT CONTRAST: The patient is intubated and has an orogastric\n tube. There are secretions around the endotracheal tube. No prevertebral soft\n tissue swelling is noted. The vertebral alignment is anatomic and no acute\n fractures are seen. CT is not able to provide intrathecal detail comparable to\n MRI. The visualized outline of the thecal sac is unremarkable. The\n surrounding soft tissue structures are unremarkable. Multiple lymph nodes are\n seen along the jugular chains bilaterally. Lymph nodes are prominent but does\n not meet size criteria for pathologic enlargement.\n\n IMPRESSION: No evidence of fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2128-08-23 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 974855, "text": " 9:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for abd trauma. thank.s\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with obvious facial trauma s/p unhelmeted MCC. +LOC. repetitive\n questioning. Confused.\n REASON FOR THIS EXAMINATION:\n please eval for abd trauma. thank.s\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMcd TUE 12:26 AM\n No evidence of trauma to abdomen or pelvis. Bilateral basilar atelectaisis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man with obvious facial trauma, status post\n unhelmeted MCC. Repetitive questioning, confused. Evaluate for abdominal\n trauma.\n\n TECHNIQUE: MDCT acquired axial images from the lung bases to the pubic\n symphysis were acquired with intravenous contrast only and displayed in 5 mm\n slice thickness for review. Multiplanar reformations were performed.\n\n CT ABDOMEN WITH CONTRAST: There is bilateral dependent atelectasis. No\n effusions are seen. No evidence of traumatic injury to liver, spleen,\n gallbladder, kidneys, pancreas, stomach, small and large bowel loops are seen.\n There is an NG tube terminating in the stomach. There is no free abdominal\n fluid or air.\n\n CT OF THE PELVIS WITH CONTRAST: The bladder contains a Foley catheter and\n excreted contrast. There is no evidence of bladder injury. There is a fat-\n containing right inguinal hernia. Pelvic small and large bowel loops and\n prostate appear unremarkable. There is no free fluid.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen. No\n fractures are identified. There are no dislocations.\n\n IMPRESSION:\n\n 1. Bilateral dependent atelectasis.\n\n 2. Otherwise, no evidence of traumatic injury to abdomen or pelvis.\n\n\n\n\n\n\n (Over)\n\n 9:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for abd trauma. thank.s\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2128-08-23 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 974856, "text": " 10:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for ETT placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p MCC, now s/p intubation for combativness\n REASON FOR THIS EXAMINATION:\n please eval for ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man status post MCC, now status post intubation for\n combativeness. Evaluate ETT placement.\n\n SUPINE PORTABLE CHEST: The endotracheal tube terminates approximately 5 cm\n above the carina. An orogastric tube is coursing into the stomach and out of\n view. Cardiac and mediastinal contours are within normal limits given\n technique. The lungs are grossly clear. No pneumothorax is seen.\n\n IMPRESSION: ETT 5 cm above the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-08-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 975007, "text": " 9:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 24 hour follo-up CT, interval change, ()\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p motorcycle crash\n REASON FOR THIS EXAMINATION:\n 24 hour follo-up CT, interval change, ()\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male after motor cycle crash referred for 24-hour\n followup CT of the head.\n\n COMPARISON: Non-contrast head CT .\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: Overall, the appearance of the brain is similar to . A\n small, oval-shaped focus of hyperdensity in the right temporal lobe is\n unchanged and likely represents a hemorrhagic parenchymal contusion. Multiple\n small foci of subarachnoid hemorrhage are again identified in both frontal\n lobes, left temporal lobe, along the interhemispheric fissure, and along the\n right side of the suprasellar cistern, not significantly changed. No new areas\n of intracranial hemorrhage are identified. The ventricular system is stable\n in size and configuration without hydrocephalus. There is no new shift of\n normally midline structures or mass effect. There is no evidence of major\n vascular territorial infarction. Again seen are areas of extensive soft\n tissue swelling of the left face as well as left frontal and biparietal scalp.\n The visualized paranasal sinuses and mastoid air cells remain clear. No\n fracture is identified.\n\n IMPRESSION: Overall, no significant interval change in appearance of the\n brain. Redemonstrated are multiple small scattered foci of subarachnoid\n hemorrhage and a small hemorrhagic parenchymal contusion of the right temporal\n lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-08-23 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 974850, "text": " 9:14 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AND AP PELVIS at 2129 hours.\n\n HISTORY: Trauma, not otherwise specified.\n\n COMPARISON: None.\n\n FINDINGS: Underlying trauma back board results in significant artifact\n obscuring portions of the imaged chest and pelvis. The extreme left\n costophrenic angle has been excluded from view. Within those limitations, the\n lungs are clear; however, lung volumes are markedly diminished. The\n mediastinum is wide, likely due to supine position and body habitus. The\n descending thoracic aorta is well defined. The cardiac silhouette is within\n normal limits for size. No obvious effusion or pneumothorax is evident. No\n displaced fractures are seen.\n\n The pelvis and sacrum are intact without evidence of fracture. Please note\n the lateral most extent of the left iliac is excluded from view, as is\n the left greater trochanter. Bilateral femoral heads are appropriately\n located. The regional soft tissues are unremarkable.\n\n IMPRESSION: Within limitations outlined above, there is no radiographic\n evidence for traumatic injury to the chest or pelvis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2128-08-24 00:00:00.000", "description": "Report", "row_id": 1627904, "text": "T/SICU NURSING PROGRESS NOTE 0700-\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE\" SECTION OF CAREVIEW. THANK YOU.\n\nPT'S WORK HAS BEEN NOTIFIED. THIS RN HAS SPOKEN WITH PT'S MOTHER, AND OWNER OF MOTORCYCLE THAT PT TOOK FOR A RIDE.\nPAIN CONTROL IS AN ISSUE. PT IS RECEIVING IV DILAUDID WHICH IS ONLY HOLDING HIS PAIN CONTROL FOR 1-1.5 HRS.\n\n HEAD CT IS SCHEDULED FOR ~8PM TONIGHT , 24 HRS AFTER THE FIRST SCAN\n" }, { "category": "Nursing/other", "chartdate": "2128-08-24 00:00:00.000", "description": "Report", "row_id": 1627905, "text": "Respiratory Care:\nPt recieved orally intubated and vented on PS. Pt extubated, good cuff leak heard prior to extubation. Placed on face tent 35%, SpO2 96-98%.\n" }, { "category": "Nursing/other", "chartdate": "2128-08-24 00:00:00.000", "description": "Report", "row_id": 1627902, "text": "Resp Care Note:\n\nPt received from ER intub with OETT and placed on mech vent as per Carevue. Lung sounds ess clear suct sm th tan sput. ABGs stable on present vent settings. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2128-08-24 00:00:00.000", "description": "Report", "row_id": 1627903, "text": "Nursing Admission Note\nPt is a 40 yo male admitted to s/p motorcycle accident. Events unclear. Pt found on side of road, ?LOC. GCS 14 in field. Pt medflighted to from scene. Per EMS pt was asking repetetive questions and very anxious, +ETOH. Anxiety increased once in , pt becoming combative. Pt intubated for combativeness and scans. Injuries include SAH in bilat frontal and L temporal lobes, R temporal contusion, L orbital fx.\n\nNeuro: Pt sedated on propofol and fentanyl. When lightened; Pt opens eyes, MAE, all of normal strength. Purposeful movement towards ETT. Pt inconsistently follows commands, ?agitation. When lightened pt becomes very agitated, trying to sit up, reaching towards ETT, and attempting to climb OOB. PERRLA, 3mm, brisk. Cough and gag intact. Pt appears to be resting comfortably with no s/s pain on fentanyl gtt.\n\nCV: NSR/ST, no ectopy. HR 70-100's. NIBP 120-130's/60-80's. +PP.\n\nResp: CMV 16x600/5/40. Most recent abg wnl. Sats 99-100%. RR 16-19. LSCTAB, dim in bilat bases. Sx'd for sm amts thick tan secretions.\n\nGI: Abd soft, nt, nd. +BS. No BM. OGT to LCS draining lrg amts pink tinged fluid.\n\nGU: Foley draining qs cyu.\n\nEndo: FSBS per SS, no coverage required.\n\nID: Afebrile. No abx at this time.\n\nSkin: Multiple abrasions to L arm, all OTA. Multiple abrasions to face, all OTA. Hematoma to L orbit.\n\nSocial: No contact from family. Per mother is \" \" and lives in .\n\nPlan: Neuro checks q2hrs. Repeat head CT today. Maintain SBP <140 per Nsurg. Wean vent to extubate after CT scan.\n" } ]

[ { "category": "Echo", "chartdate": "2174-01-24 00:00:00.000", "description": "Report", "row_id": 73702, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 152\nBSA (m2): 1.66 m2\nBP (mm Hg): 164/68\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:29\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: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. 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.\n\nAORTIC VALVE: Moderate AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\ncalcification. Moderate (2+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nSevere PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. There is moderate aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is severe mitral annular calcification with a moderate inflow\ngradient (in part due to significant regurgitation). Moderate (2+) 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 severe pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2174-01-25 00:00:00.000", "description": "Report", "row_id": 166577, "text": "Ventricular paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2174-01-24 00:00:00.000", "description": "Report", "row_id": 166578, "text": "Ventricular paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2174-01-21 00:00:00.000", "description": "Report", "row_id": 166581, "text": "Supraventricular rhythm, rate 140 with 3:1 A-V conduction. Occasional\nventricular ectopy. Prior anteroseptal myocardial infarction. T wave inversions\nin leads I and aVL and ST segment depression in leads V4-V6 which may represent\nconcomitant ongoing ischemia. The rhythm is new compared to the previous\ntracing of . Followup and clinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2174-01-23 00:00:00.000", "description": "Report", "row_id": 166579, "text": "Sinus rhythm, rate 90 and ventricular paced rhythm, without intrinsic\nA-V conduction. Compared to the previous tracing of no diagnostic\ninterim change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2174-01-22 00:00:00.000", "description": "Report", "row_id": 166580, "text": "Sinus rhythm, rate 62 and ventricular paced rhythm in the absence of atrial\nsensing. The pacemaker is new. Compared to the previous tracing of .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-01-26 00:00:00.000", "description": "Report", "row_id": 170194, "text": "Atrial sensed and ventricular paced rhythm. Compared to the previous tracing\nof the rhythm is now atrial sensed and ventricular paced.\n\n" }, { "category": "Radiology", "chartdate": "2174-01-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 896578, "text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: eval position of leads\n Admitting Diagnosis: COMPLETE HEART BLOCK\\PACEMAKER IMPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dual chamber pacemaker\n REASON FOR THIS EXAMINATION:\n eval position of leads\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dual chamber pacemaker placement.\n\n Since , the temporary right-sided pacer has been removed. A\n new dual chamber bipolar pacer seen in the left chest wall with leads\n terminating in the right atrium and right ventricle. Again seen is some mild\n bilateral atelectasis as well as blunting of the costophrenic angles\n consistent with small pleural effusions. Extensive calcification is seen in\n the heart consistent with calcified mitral annulus.\n\n IMPRESSION: New left-sided pacer with leads in the right atrium and\n ventricle. No evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2174-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 896069, "text": " 9:22 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Rt Pneumothorax?Lead Position?\n Admitting Diagnosis: COMPLETE HEART BLOCK\\PACEMAKER IMPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with a temporary screw-in pacemaker lead in .RV . Rt\n subclavian vein approach pacemaker attached to Rt upper chest (externally)\n\n REASON FOR THIS EXAMINATION:\n Rt Pneumothorax?Lead Position?\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Pacemaker placement.\n\n Chest: A single semi-upright AP view at 9:30 p.m. is compared to previous\n examination earlier from the same day. Since the previous exam the\n interstitial edema has decreased. There is an endotracheal tube with the tip\n approximately 4.5 cm proximal to the carina. There is a new single lead\n pacemaker with the lead overlying the right ventricle. There is no evidence of\n pneumothorax. There are probable pleural calcifications in left lower lung.\n There is focal opacity in right upper lobe which may represent pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2174-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 896087, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax, lead placement and pneumonia\n Admitting Diagnosis: COMPLETE HEART BLOCK\\PACEMAKER IMPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with a new temporary screw-in lead in RV with rt sided\n pacemaker attached to rt chest externally and pneumonia\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax, lead placement and pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Right-sided pacemaker.\n\n Chest: A single AP view is compared to previous examination of .\n Since the previous exam there has been insertion of an NG tube with the tip\n below the diaphragm. The position of the endotracheal tube is unchanged.\n Again note is made of right-sided single lead pacemaker with the lead\n overlying right ventricle.\n Again note is made of focal parenchymal opacity in right upper lung,\n suggesting pneumonia. Mild interstitial pulmonary edema persists. There is\n cardiomagaly. Note is made of linear atelectasis versus scarring in left\n suprahilar region. There is also bibasilar atelectasis. There is a suggestion\n of pleural calcifications in left lower lung.\n\n" }, { "category": "Radiology", "chartdate": "2174-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 896033, "text": " 4:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n No prior films for comparison.\n\n INDICATION: Pneumonia.\n\n Heart is enlarged and there is vascular engorgement and bilateral perihilar\n haziness as well as bilateral septal thickening. Additionally, there is\n asymmetrical perihilar haziness with more confluent areas of developing\n airspace consolidation in the right upper and right lower lobes. Small\n pleural effusions are seen bilaterally.\n\n IMPRESSION: Findings may relate to asymmetrical congestive heart failure or\n congestive heart failure superimposed upon underlying pneumonia in the right\n lung.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-01-22 00:00:00.000", "description": "Report", "row_id": 1263752, "text": "NURSING PROGRESS NOTE\nS: INTUBATED AND SEDATED\n\nO: PT. IS A 84 Y/O FEMALE WHO RESIDES IN HOME. PMH INCLUDES CAD, HTN, HIGH CHOLESTEROL, ADVANCED ALZHEIMER'S DISEASE WITH APHASIA, PNEUMONIA, DEPRESSION. WHILE AT NH HEART RATE WAS IN THE 40'S AND SHE WAS BROUGHT TO ER WHERE EKG SHOWED CHB. SHE WAS TRASNFERED TO FOR FURTHER MANAGEMENT. A TEMP SCREW PACER WAS INSERTED WITH PLANS FOR A PERM PACER NEXT WEEK. SHE IS BEING TREATED FOR ACTIVE PNEURMONIA WHICH DID NOT RESPOND TO ERYTHROMYCIN/LEVAQUIN WHILE IN THE NURSING HOME.\n\nNEURO: PT. INTUBATED FOR AGITATION/PACER PROCEEDURE. PROPOFOL GTT STARTED FOR SEDATION. OPENS EYES SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS. DOES HAVE BREAKTHROUGH AGITATION WHILE ON PROPOFOL GTT REQURING SMALL BOLUSES 1-2 CC OF PROPOFOL. SOFT WRISTS RESTRAINTS ON FOR PT. SAFETY/PREVENT POSSIBLE EXTUBATION AND LINE/PACER DISPLACEMENT. LIFTS AND HOLDS UPPER EXTREMITIES, MOVES LEGS ON BED.\n\nCV: VVI PACER TEMP SCREW IN PLACE. DRESSING INTACT, NOT TO BE REMOVED. RATE 60, 100% PACED. PACER INSERTED WIA RIGHT SUBCLAVIAN, SITE C&D. BP LABILE WHILE ON PROPOFOL. NOW 128-131/62.\n\nRESP: SEE RESP FLOWSHEET FOR DATA. SUCTIONING FOR MODERATE AMTS OF THICK YELLOW SPUTUM. CULTURE OBTAINED AND SENT. COARSE BREATH SOUNDS. ON COMBIVENT INHALER. O2 SAT 100% ON FIO2 60%.\n\nGU: FOLEY IN PLACE. DRAINING CLEAR YELLOW URINE. UA/C&S OBTAINED AND SENT TO LAB. RECEIVED 20 MG LASIX IV IN CATH LAB. SEE FLOWSHEET FOR I/O. ON DALIY LASIX DOSE.\n\nGI: + BOWEL SOUNDS. NO BM OVERNIGHT. OGT PLACED. DRAINING SMALL AMTS OF WHITE GASTRIC FLUID. ABD SOFT.\n\nID: AFEBRILE, PAN CULTURED ON ADMISSION. TEMP MAX 97.8 ORAL. ABX COVERAGE LEVAQUIN & CEFAZOLIN IV.\n\nCODE STATUS: WAS A DNR/DNI AT NURSING HOME, STATUS REVERSED FOR PROCEEURE. WILL DISCUSS WITH FAMILY TODAY AS TO CODE STATUS WISHES WHILE AT .\n\nA/P: BRADYCARDIC/CHB TEMP PACER INSERTED. PNEUMONIA.\nPLAN FOR PERM PACER LATER NEXT WEEK. ON ABX FOR PNEUMONIA. MONITOR LYTES AND REPLETE AS NEEDED, FOLLOW CPK, MAINTAIN DRESSING PATENCY OVER PACER SITE. ADDRESS CODE STATUS WITH FAMILY. ? POSSIBLE EXTUBATION TODAY PER MEDICAL TEAM. UPDATE FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-22 00:00:00.000", "description": "Report", "row_id": 1263753, "text": "Respiratory Therapy\nPt arrived from cardiac cath lab orally intubated. Placed on A/C 500X14 5peep 1.Sx for copious thick creamy yellow/tan secretions sent to lab. Successive suctionings produced mod amts thick white secretions. BS initially coarse with diffuse wheezes. Combi MDI given W good effect. Plan wean to ext.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-22 00:00:00.000", "description": "Report", "row_id": 1263754, "text": "RESPIRATORY CARE: PT EXTUBATED AFTER A SBT AND AN RSBI\nOF 60. EXTUBATED TO A 40 % AEROSOL MASK AND DOING WELL.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-22 00:00:00.000", "description": "Report", "row_id": 1263755, "text": "ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\ns: \"take it out\"\no: id: afeb. abx changed to ceftriaxone and azithromycin, rec'd 1st doses of each.\ncv: generally vpaced at 60 via r sc tranvenous pacer. bp 110-140/50-70. l rad aline dc'd.\nresp: weaned and extubated this am. now on ra. rr 20s, nonlabored, nonprod cough. bs scatt coarse. sats >93% on ra.\ngi: taking sips of fluids and mouthfuls of soft solids. needs cuing to swallow, supervision for aspiration precautions. abd soft, benign. passing gas. no stool.\ngu: foley to . diuresed to 40mg iv lasix given this am.\nms: alert, able to focus, follow commands. mae w purpose. agitated at times. has difficulty verbalizing. appears afraid. has soft wrist restraints to maintain ivs, pcm. minimizing risks w removal of aline. has sitter also at this time to prevent pt dislodging temp pacing device. daughter and son visited, updated.\na: temp wire awaiting ppcm for chb. alt ms r/t dementia. pna\np: safety precautions. monitor rhythm, hemodynamics, resp exam. provide support to pt and family. remains full code.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-23 00:00:00.000", "description": "Report", "row_id": 1263756, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I WANT \", YES I AM WARM ENOUGH\"\n\nO: NEURO: SLEPT IN SHORT NAPS OVERNIGHT. APPEARS FRIGHTENED WHEN APPROACHED. VERBAL AT TIMES, OTHER TIMES GRUNTING. FOLLOWS MINIMAL COMMANDS. SITTER AT BEDSIDE TO PREVENT PT. FROM DISLODGING PACER, IV LINES. WRIST RESTRAINTS OFF.\n\nCV: HR 60-68 VPACED. BP STABLE. RIGHT SUBCLAVIAN PACER SITE INTACT. DRESSING INTACT.\n\nRESP: ON ROOM AIR. O2 SAT 95%. NON-PRODUCTIVE COUGH. LUNGS CLEAR.\n\nGU: FOLEY DRAINING SMALL AMTS OF YELLOW URINE.\n\nGI: TAKING SMALL SIPS OF APPLE JUICE WITH ASSISTANCE. + BOWEL SOUNDS, PASSING GAS, NO BM OVERNIGHT.\n\nID: AFEBRILE, CONT ON ABX FOR PNEUMONIA\n\nA/P: S/P TEMP PACER INSERTION FOR CHB, WAITING FOR PERM PACER EARLIER NEXT WEEK. ENCOURAGE PO INTAKE, FOLLOW LABS, REPLETE LYTES AS NEEDED, PROVIDE CALM, REASSURING ENVIRONMENT TO PT. SITTER FOR PT. SAFETY. UPDATE PLAN OF CARE WITH FAMILY OER CCU TEAM.\n" } ]

[ { "category": "Echo", "chartdate": "2108-06-18 00:00:00.000", "description": "Report", "row_id": 72157, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 98/62\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 11:46\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate\nregional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; basal anteroseptal - hypo; mid anteroseptal - akinetic; anterior\napex - akinetic; septal apex- akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. There is mild regional\nleft ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include anteroseptal, anterior and apical akinesis/hypokinesis.\nNo definite apical thrombus idenitifed (cannot exclude). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (+) mitral regurgitation is\nseen. There is a trivial/physiologic pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2108-06-16 00:00:00.000", "description": "Report", "row_id": 1365595, "text": "ccu nursing progress note\ns: can i get a muscle relaxant to help me sleep?\no: pls see carevue flowsheet for complete vs/data/events\npleasant, conversant 77yr old male s/p ami and stent to lad. single vessel dx. pcw 22, w vea in cath. adm to ccu for monitoring.\n\nneuro: a/ox3. , w purpose. visiting w wife and dtr this afternoon and this eve.\ncv: hr 90-110sr w pvcs diminishing over past sev hours. bp 90-120/50-60 via nbp. has trans hypotension during sheath pull req .5 atropine and ns bolus w resolution.\non integrillin at 2mcg/kg/min to complete at 6am. plts 204.\nck 1100 at 1pm, 2nd pend.\nr fem site has cont slow ooze from (not puncture site). mod prs dsg applied w some effect. pulses dop/+. feet cool bilat.\npost cath ivf at 50cc/hr to complete 2l. 1st l up currently.\nresp: cxs at bases. no sob. sats improved on nc 2l 95-98%.\ngi: drinking water, enc to limit intake while diuresing. had episode of n/v after eating crackers, resolved quickly after emesis.\ngu: condom cath. rec'd 20mg lasix in cath w good response.\na: ami, s/p stent, chf\np: assess need for further diuresis, follow for bleeding complications. follow rhythm, chf, hemodynamics. monitor for s/s etoh w/d. support and education to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2108-06-17 00:00:00.000", "description": "Report", "row_id": 1365596, "text": "ccu npn 7p-7a\nS:\"I feel nauseous and my chest has a dull ache.\"\nO: Please see carevue for VS and objective data\nCVS: Episode of nausea, mild chest pain at , see carevue for details. Given one SL NTG with SBP briefly down to 70's, responded to 250cc NS bolus. EKG without worsening ST elevation. CCU team in to assess and treat. Card. fellow notified. HR 90's-70's NSR, tolerated 12.5mg po Lopressor. Captopril held this shift with recent hypotension. BP ranges now 90's-120/60-70. CPKS 2213/. IV Integrelin at 2mcg/kg/min. to be dc'd at 0600. Right groin D/I without palp. hematoma. Distal pulses per flow. Podt cath hydration 1/2 NS at 50cc/hour. K 3.7, repleted with 40meq po KCL. Mg 1.7, repleted with 2amps IV Magnesium sulfate.\nResp; Sats briefly down to low 90's in setting of CP, nausea. Sats now 95-97% on 4L N/C. Lungs with fine bibasilar rales. RR 18-21. Without further diuresis ordered this shift.\nGI:GU: Episode of nausea responded to 10mg IV Compazinex1. Pt. able to take po meds without further n/v. Abdomen soft with active bowel sounds, no stool this shift. Condom catheter in place, draining clear, yellow urine. One episode of incontinence when catheter fell off. Total I/O approx. 800cc postive at MN. Creat 0.7\nID: afebrile\nNeuro; Pt. A/A/0X3, cooperative with care. Strong history of ETOH use. CIWA scale per flow. Pt. mildly anxious and restless at times. Requesting \"muscle relaxant\", stating \"its hard to stay on my back or in this bed.\" MAE. Given 5mg po Valium at 2100, 2300, 0230. Pt. dozing at intervals only. Easily arousable and bedrest maintained.\nA: hemodynamically stable s/p Ant. MI requiring cypher stent to LAD. Brief episode of nausea/chest pain.\nP: Cont to assess for ischemia, IV Integ. until 0600. Post cath IVF X2L. Assess resp. status closely, prn diuresis. Cont to monitor groin site. Follow up with am labs. Cont to assess for s/s etoh withdrawal. Comfort and emotional support to Pt. and family.\n" }, { "category": "Radiology", "chartdate": "2108-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 870551, "text": " 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION/CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p STEMI\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 19:27.\n\n INDICATION: Stemi, check for failure.\n\n Comparisons: None available.\n\n FINDINGS:\n\n The right lateral costophrenic sulcus is obscured from view but the left shows\n no evidence of blunting. There is no consolidation and the pulmonary vascular\n markings are within normal limits. Heart size and mediastinal contours are\n normal.\n\n IMPRESSION:\n\n No radiographic evidence for acute cardiopulmonary disease.\n\n\n" }, { "category": "ECG", "chartdate": "2108-06-18 00:00:00.000", "description": "Report", "row_id": 180735, "text": "Sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nRecent anteroseptal infarct\nLow QRS voltages in precordial leads\nSince previous tracing of , evolution of anteroseptal myocardial\ninfarction present\n\n" }, { "category": "ECG", "chartdate": "2108-06-17 00:00:00.000", "description": "Report", "row_id": 180736, "text": "Sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nProbable acute septal infarct\nPossible old inferior infarct\nLateral ST elevation - repeat if myocardial injury is suspected\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2108-06-16 00:00:00.000", "description": "Report", "row_id": 180737, "text": "Sinus rhythm.\nLeft axis deviation\nRBBB with left anterior fascicular block\nLateral infarct - age undetermined\nPOSSIBLE ACUTE ANTEROSEPTAL INFARCT\nInferior T wave changes are nonspecific\nLimb leads reversed\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2135-04-18 00:00:00.000", "description": "Report", "row_id": 1540616, "text": "SOCIAL WORK NOTE:\n\nNew trauma pt on T-SICU who came in over the weekend. Pt is a 39 year old single woman who lives in with her cat. She is a nurse and works as a nurse manager at Nursing Home. Pt was in a rollover MVC over the weekend and sustained a traumatic left arm amputation (?above the elbow). Pt is intubated and sedated at this time.\n\nThis SW introduced self to pt's , and , and pt's brother, , and then met with to gather information about pt, explain role of SW and offer support. They report that pt is not married and does not have any children. They describe her as a very hard worker who works long hours at her job. Pt has 5 siblings (4 brothers and a sister) all of whom live locally. live in .\n\nPt's are not aware of pt having any psychiatric or substance abuse history. Pt's etoh level at time of testing in ED was 217. ICU Team has consulted with psychiatry for assistance as needed when pt is extubated and learns of amputation. Social Work is available for pt support as well. This SW will be away after tomorrow and this was explained to . They are aware that social work will remain involved as needed - whether pt remains on unit or goes out to floor.\n\nPager .\n" }, { "category": "Nursing/other", "chartdate": "2135-04-18 00:00:00.000", "description": "Report", "row_id": 1540617, "text": "NPN (0700-) Review of Systems:\n\nNeuro: Pt sedated on propofol, easily aroused. Propofol lightened 2' weaning of vent. Pt following coommands and nodding head appropriately. PERRL. MAE. Pt nodds not when asked of have pain. IV MSO4 at 3mg/hr. Pt noted to have increased anxiety as propofol lightened. IV ativan prn. Logroll and c spine precautions maintained. CT scan of head, neck, abd and tls done, awaiting results and clearing of spine. Psych consulted and SW in touch with family.\n\nCV: ST with hr=110-120s, no ectopy. SBP=120-150s and up to 170s with stimualtion and turning. Labatalol prn sbp>160, given x1. Color pink, skin warm and dry. Venodynes in place.\n\nREsp: LS clear to occasionally course at bases. A/C ventilation weaned to pressure support of 8 & PEEP of 5, pt tolerateing with rr=, TV=500-600s, and SaO2=98-100% on 50%. ABG more acidotic, Team aware, continuing to wean propofol. Pt suctioned for scant amoutn of thick white secretions.\n\nGI: Abd softly distended. Absent BS. NGT to LCWS and draining bilious drainage. IV protonix and reglan continues.\n\nGU: Indwelling foley intact and draining sufficient quantity of clear yellow urine. Potassium and calcium repleted.\n\nHeme: HCT=29.7, continue to follow qd per team. SQ heparin continues.\n\nID: Tmax=101.0po. WBC=12.5(15.2). IV cefazolin and gentamycin continue. GEnta peak and trough drawn.\n\nEndo: No issues.\n\nSkin: Skin warm and dry. LUE with original dressing from OR, ace wraped. JP drain intact and draining ss drainage. Skin care provided, no other breakdown noted.\n\nSOC: Pt's in and talked with MD , very supportive and questions answered. Family concerned about telling pt of LUE. Pt has 5 other siblings, two in tonight.\n\nA/P: Continue support as above. Plan to wean sedation and vent to extubation as tolerated. Await CT scan results. Continue pain management. Provide emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-17 00:00:00.000", "description": "Report", "row_id": 1540614, "text": "NSG NOTE\nPT ADMITTED AT 2PM FROM PACU S/P LUE AMBUTATION.\nSHE WAS INTUBATED WITH #7 ENDO TUBE WHICH DEVELOPED A CUFF LEAK SO SHE NEEDED TO HAVE THE TUBE CHANGED.SHE IS ON A PROPOFOL AND MSO4 QTT.\nSHE IS HEMODYNAMICALLY STABLE,SOMEWHAT TACKY.T 99.4.UO 80-100CC HR.\nSHE IS RECEIVING 100CC HR RL.\nTHE LARM DSD IS INTACT,JP IS DRAINING WELL.\n\n PLAN IS TO KEEP PT SEDATED OVER NIGHT.SHE WILL NEED A HEAD AND ABD CT IN AM BEFORE ANY ATTEMPT TO WEAN AND EXTUBATE.\n\n HER FAMILY HAVE BEEN IN .THEY HAVE SPOKEN TO THE DRS ARE AWARE OF PLANS.\n\n" }, { "category": "Nursing/other", "chartdate": "2135-04-18 00:00:00.000", "description": "Report", "row_id": 1540615, "text": "NURSING PROGRESS NOTE\nS/O- STABLE HEMODYNAMICALLY, TMAX 100.2. TACHY AT 100-106, NO ECTOPY. LYTES REPLETED HCT 29.7, INR 1.3.\nNEURO PT ON PROPOFOL AND MORPHINE GTT FOR SEDATION, INCREASED TO 80 MCG/KG/MIN. PT ABLE TO MOVE ALL EXTREM TO COMMAND. OPENS EYES TO VOICE. PERL. LOG ROLLED, C COLLAR ON.\n PT REMAINS VENTED , 700X14 ON 50% FIO2 WITH 5 PEEP WITH GOOD ABG, 173-34-7.42-1. SUCTIONED FOR THICK BLOOD TINGED SECRETIONS, , AFTER SUCTIONING PT HAD , REQUIRING INHALER, WHICH RESOLVED BRONCHOSPASM.\nGI- ABD IS SLIGHTLY DISTENDED AND SOFT, NG TO SUCTION INITIALLY DRAINING FOOD, NOW BROWN. NOT STOOL OR FLATUS NOTED.\n PT HAS BRISK U/O WHILE RECEIVING 100CC HR OF RL.\nSKIN- SKIN ON BACK AND BUTTUCKS IS INTACT, DSG ON LT AMPUTAION SITE IS DRY AND INTACT WITH JP DRAINING 60CC Q4H.\nA/ PT TO HAVE SCAN OF ABD AND HEAD TODAY AND NEEDS SPINE CLEARED, EXTUBATE AFTER SCANS. METABOLIC ACIDOSIS RESOLVED. NEURO APPEARS INTACT. PT WILL CONT REQUIRE PAIN MANAGEMENT POST EXTUBATION AS WELL AS EMOTIONAL SUPPORT AS SHE BECOMES MORE AWAKE AND AWARE OF HER INJURY. CONT TO MONITOR AND ASSESS.\n\n" }, { "category": "Nursing/other", "chartdate": "2135-04-21 00:00:00.000", "description": "Report", "row_id": 1540626, "text": "Nursing Progress note, See transfer note in chart.\n\nS: \"I'll get over this in time, it will just be hard to tie my shoes.\"\n\nO: Review of Systems:\n\nNeuro: Pt 3, answering questions appropriately, MAE. Pt +smoker, nicotine patch in place. MSO4 PCA for pain, pt using s difficulty and reports pain control.\n\nCV: ST c hr=100-110s, no ectopy. SBP=110-130s. Color pink and venodynes in place.\n\nResp: LS course and dimminished. O2 weaned to 2L NC and pt tolerating well with SaO2=96-100%. +NPC though pt reports it hurts to cough at timed. C &DB encouraged.\n\nGI: Abd soft c + BSx4. Pt tolerating regular diet. Deneis N/V/D. Reports +flatus, no bm.\n\nGU: Indwelling foley intact and draining clear yellow urine. Pt given 1x dose of 10mg IV lasix, I&Os continue to be negetative.\n\nHeme: AM HCT=23.1(23.8). Plan to continue to follow.\n\nID: Afebrile. WBC=9.8. IV cefazolin continues.\n\nEndo: No issues.\n\nSkin: Skin warm and dry. LUE with ace wrap intact. L ear laceration with dsd and sm amount of s drainage. Back with pink rash, improving, pt reports she has very sensitive skin.\n\nSOC: Family in, very supportive.\n\nA/P: Continue to monitor as above. Continue pain management and emotional support. Plan to transfer to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-20 00:00:00.000", "description": "Report", "row_id": 1540622, "text": "S/P MVA-TRAUMATIC AMP LUE-T/SICU NPN 11P-7A\nS-\"CAN I GET SOME MORE WATER PLEASE.\"\nO-NEURO-SLEEPY BUT EASILY AROUSABLE,MAE'S.A+O X3 ,CALM COOPERATIVE.VOICE/COUGH STRIDOROUS INITIALLY IMPROVED W/ NEBS AND ICE.\nCV-SBP 110'S-130'S,HR 100'S-120'S,ST NO VEA.3+DP/PT .IVF D51/2NS W/ 20MEQ KCL/L @ 80CC/HR IV MAINT.\nRESP-INSP/EXP WHEEZING STRONG PROD COUGH.NEBS ORDERED AND GIVEN Q4H,W/ IMPROVEMENT IN SYMPTOMS,O2 SATS INITIALLY 94-96% ON 100%FT/2L NC.PT NOW ON 50%/2L NC AND O2 SATS98-100%.RR16-22.PT DENIES SOB.\nGI/GU-PT SIPS H20 OVER NOC ADAT TODAY.PT ABD OBESE + HYPOACTIVE BS.U/O ADEQ CLEAR YELLOW URINE VIA FOLEY.\nSKIN-LUE STUMP DSG CDI JP W/ ~30 CC SEROSANG DRAINAGE OVER NOC.L EAR LAC OPEN .5CM X 1.5CM ADAPTIC APPLIED MIN DRAINAGE.ANASARCA.\nID-CONT'S ON GENTA/CEFAZ.AFEBRILE OVER NOC.\nA-PERSISTENT TACHYCARDIA\nP-MONITOR NEURO STATUS QS AND PRN,VS,IVF/ORDERS.I+O,NEBS PRN/ORDERS,CONT TO MONITOR RESP STATUS QS AND PRN,O2 PRN,IV ABX/ORDERS.MONITOR SKIN INTEGRITY QS AND PRN.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-20 00:00:00.000", "description": "Report", "row_id": 1540623, "text": "NURSING TRANSFER NOTE 0700-1200\nHAND WRITTEN TX NOTE IN CHART AND FAXED TO FLOOR.\n\nBRIEFLY, PT REMAINS AT 110-120 ST. BP STABLE AT 112-120'S. IVF AT KVO FOR PCA WHICH WAS STARTED AT 1200. MSO4 GTT OFF. NICOTINE PATCH APPLIED AT 1200. ? CAUSE OF TACHYCARDIA . PT IS AFEBRILE.\n\nLUE DRG CHANGED BY ORTHO. SITE CLEAN WITHOUT OOZE. ACE WRAP REAPPLIED.\nOOB TO CHAIR WITH ASSIST ON ONE. PT IS NOT ORTHOSTATIC. L EAR HAS LAC.\n\nOF NOTE, PT 2 DECREASES TO 80'S WITHOUT FACE TENT AT 100% AND 4L NC. THE TEAM IS AWARE OF THIS AND A CXR IS ORDERED . LUNGS COARSE IN UPPER AIRWAYS , DECREASED IN BASES. PT HAS A NON-PRODUCTIVE COUGH.\n\nSTARTED ON PO'S , EATING TOAST AND JUICE FOR BREAKFAST.\n\nAUTODIURESING.\n\nPT IS TO BE TX TO FLOOR AFTER CXR DONE AND READ.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-20 00:00:00.000", "description": "Report", "row_id": 1540624, "text": "ADDENDUM TO NOTE\nCXR REVEALED WET LUNGS WITH PATCHY INFILTRATES. PT'S SA02 REMAINS THE SAME. PT'S TX HAS BEEN CANCELLED FOR TODAY. PT RECEIVE LASIX LATER TODAY\n" }, { "category": "Nursing/other", "chartdate": "2135-04-21 00:00:00.000", "description": "Report", "row_id": 1540625, "text": "S/P MVA TRAUMATIC AMP LUE T/SICU NPN 7P-7A\nS-\"COULD THE GIVE ME ANOTHER TREATMENT?\"\nO-NEURO-INTACT\nCV-SBP 100'S-130'S,HR 100'S-110'S ST NO VEA.3+DP/PT \n COARSE->BRONCHIAL-->DIMINISHED W/ DIMINISHED BASES AND OCCAS CRACKLES,O2 SATS 96-100%,NC DC'D,FIO2 WEANED FROM 50->40% VIA FT NEB,NEBS/RT X 3 OVER NOC.RR 20-24.NARD,STRONG NONPROD COUGH EFFORT.CXR DONE THIS AM @ 6:30AM.\nGI/GU-PT ABD OBESE + BS, SIPS H20 OVER NOC DENIES N/V,U/O ADEQ CLEAR YELLOW URINE VIA FOLEY.\nSKIN-NEW MACULAR PINK DIFFUSE RASH OVER PT'S BACK,TRAUMA HO AWARE,LUE STUMP DSG CDI W/ACE WRAP,SM SEROSANG OUTPUT VIA JP.\nSOC-PT FAMILY ON EVES.\nID-AFEBRILE CONT'S ON CEFAZ IV.\nCOMFORT-USING PCA MSO4 APPROPRIATELY\nA-RESP STATUS CONT TO IMPROVE.\n PT WILL TRANSFER TO FLOOR TODAY,PCA/ORDERS.MONITOR EFFECT.O2 PRN/ORDERS.I+O,MONITOR SKIN INTEGRITY QS AND PRN.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-19 00:00:00.000", "description": "Report", "row_id": 1540620, "text": "NPN (0700-1530) Review of Systems:\n\nNeuro: Pt arouses easily, IV propofol weaned to off while weaning vent. IV MSO4 drip at 3mg/hr decreased to 1.5mg/hr 2' decrease sedation. Pt denies pain. Pt follows commands, MAE and mouths words appropriately. PERRL. Pt anxious at times once propofol weaned, IV ativan given with effect. Approx 1300, pt noted to have collar off. Dr d/c'd collar, c spine precautions and logroll precautions. PSYch following.\n\nCV: HR=100-130 ST with occasional PVCs. SBP=120-160 with short episodes up to 180 when coughing and anxious. Color pink. Venodynes intact. R femoral line d/c'd by Dr and site intact. 2md PIV placed.\n\nResp: LS dm at bases. IMV weaned to PSV of and pt tolerating well with rr=, TV=300-600 and SaO2=98-100% on 50% Fio2. ABG more acidotic with ph=7.3 and CO2=52 on PSV. Dr aware and plan to extubate.\n\nGI: Abd softly distended. + hypoactive BS. NGT to LWS and draining bilious drainage. No BM. IV protonix and reglan continue.\n\nGU: Indwelling foley intact and draining 30-60cc/hr yellow urine. Potassium and calcium repleted.\n\nHeme: AM HCT=25.4(29.7), SICU team aware and no further intervention at this time. Plan to continue to follow.\n\nID: Tmax=101.0 po. AM WBC=11.6(12.5). IV cefazolin and gent continue.\n\nEndo: No issues.\n\nSkin: Skin warm and dry. LUE with original OR dressing D&I. JP drain draining sm amount of ss drainage. L ear lac s drainage and ota. Skin care provided.\n\nSOC: and siblings in, very supportive and questions answered.\n\nA/P: Continue support as above. Plan to extubate. Continue pt and family emotional support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-04-19 00:00:00.000", "description": "Report", "row_id": 1540621, "text": "T/SICU NPN 3-11PM\nS: \"I'M OKAY\"\nO: NEURO: AWAKE AND ALERT, COOPERATIVE. AWARE OF LUE AMPUTATION. FOLLOWS COMMANDS.\nCV: HR TACHY 120'S, OCCAISIONAL PVC. BP STABLE. A-LINE D/C'D. IVF D51/2NS WITH 20KCL AS MAINTENANCE IVF AT 80CC/HR.\nRESP: EXTUBATED AT 1530, FACE TENT INITIALLY ON 50% FIO2 BUT WITH O2 SATS DECREASING, IMPROVED WITH FIO2 UP TO 100%. O2 SATS DOWN TO 85-90 WITH O2 OFF. STRONG COUGH. REPORTS THROAT FEELING IRRITATED.\nGI: NGT PULLED. TOLERATING CLEAR LIQUIDS.\nGU: FOLEY DRAINING CLEAR URINE\nHEME/ID: TEMP TO 101.3, HO AWARE. NO CULTURES. GIVEN TYLENOL. TEMP DOWN TO 100.4. CONT ON GENT AND CEFAZOLIN\nSKIN: ACE WRAP TO LUE INTACT. ELEVATED ON PILLOWS. LACERATION BEHIND LEFT EAR, CLEANSED AND BACITRACIN AND 2X2 ON\nPAIN: ON MSO4 GTT, INCREASED FROM 1.5MG/HR TO 2MG/HR WITH GOOD EFFECT, RARE NEED FOR BOLUS. REPORTS FEELING THROBBING AND SOMETIMES \"PINS AND NEEDLES\" SENSATION IN LEFT ARM.\nSOCIAL: FAMILY IN VISITING. PT AWARE OF LUE AMPUTATION. ACTING APPROPRIATELY, STATES \"IT HAPPENED\". NOT ELABORATING ON FEELINGS.\nASSESS: STABLE POST EXTUBATION. PAIN UNDER GOOD CONTROL.\nPLAN: CONT PER PLAN, PAIN MANAGEMENT, PULM HYGIENE, FOLLOW TEMP.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-19 00:00:00.000", "description": "Report", "row_id": 1540618, "text": "T/SICU Progress Note\nS/O: Neuro: Denies pain, following commands on Propofol 20. Became agitated with tachycardia and hypertension, c/o not being able to breath. TLS films not read, so propofol increased to 50. Pt comf and sleeping when not stimulated, able to tolerate turning and procedures with 20-30 mg propofol by bolus. MSO4 3mg/hr.\n CV: HR 105-120 NST, occl PVC when agitated. BP 120/70.\n Resp: Resp acidosis on CPAP with 8 on 50 propofol despite rr 12 and Vt 400s. IMV 700X12, 50%, 8 , pt in phase with vent, abg 144 42 7.42. Small amt sticky white sputum. BS diminished.\n Renal: UO 50-130/hr. I&O +170 for . BUN/Cr 5/.4. K (80 meq), Mg(4) and Ca (4) repleted.\n Heme: Hct 25.4(29.7). INR 1.1. SQ heparin and pneumoboots.\n ID: Tmax 38.3, wbc 11.6 (12.5), on kefzol and genta (peak 2.3).\n GI: 950cc bilious drg from ngt . On protonix. No nutritional support yet.\n Endo: Glu wnl.\n Skin: Lac left ear, blistering front of chin.\n Family: Here in evening.\nA: Sedated and ventilated until status of TLS determined. ?drop in hct.\nP: ?transfuse. Wean and extubate when TLS films read. Watch face. ?stitch ear. Family and psych support.\n" }, { "category": "Nursing/other", "chartdate": "2135-04-19 00:00:00.000", "description": "Report", "row_id": 1540619, "text": "SOCIAL WORK NOTE:\nSpoke with pt's again earlier today while they were awaiting visitation with pt. Pt remained intubated earlier today. Pt's report that a friend of pt's recommended to them that they apply for Social Security Disability for pt. They believe strongly that pt will want to continue at her current job. This SW encouraged them to be informed by pt's wishes in this regard when they are able to communicate with her. aware that this SW will be away after today and they are aware of coverage plan. Pager .\n" }, { "category": "Radiology", "chartdate": "2135-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756378, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: REPOSITION OF ETT\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE PORTABLE CHEST RADIOGRAPH .\n\n INDICATION: Post intubation and repositioning of endotracheal tube.\n\n Comparison is made to study of 15 minutes previously. The endotracheal tube\n has been withdrawn and is seen 5.5 cm above the carina. There interval re-\n expansion of the right lung. The heart size and pulmonary vasculature are\n normal. There is slight blunting of the right cardiophrenic angle which may\n be positional.\n\n IMPRESSION: Endotracheal tube located 5.5 cm above the carina with interval\n re- expansion of the right lung.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756375, "text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with s/p mvc\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE PORTABLE CHEST RADIOGRAPH .\n\n INDICATION: Post intubation.\n\n Since the prior study of 1 hour ago, the patient has been intubated. The\n endotracheal tube is located within the left main stem bronchus. There is\n complete whiteout of the right hemithorax with obscuration of the right\n hemidiaphragm and right heart border. The left lung fields are clear.\n\n IMPRESSION:\n 1. Left main stem intubation with collapse of the right lung.\n 2. The endotracheal tube was repositioned and repeat films were taken before\n this film was reviewed by the reporting radiologist.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-17 00:00:00.000", "description": "L HUMERUS (AP & LAT) LEFT", "row_id": 756376, "text": " 7:58 AM\n HUMERUS (AP & LAT) LEFT Clip # \n Reason: s/p open transecting fracture, , of left forearm. FULL view\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with s/p mva\n REASON FOR THIS EXAMINATION:\n s/p open transecting fracture\n\n of left forearm. FULL views of entire left extremity and shoulder.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE ELBOW .\n\n INDICATION: Open transsecting fracture post trauma.\n\n No prior studies are available for comparison.\n\n A single AP view of the elbow shows complete dislocation with marked medial\n displacement of the ulna and radius in relation to the humerus. The olecranon\n process appears to have been fractured off the ulna as it is not seen. There\n are also fracture fragments around the medial and lateral epicondyles. There\n extensive soft tissue swelling and subcutaneous emphysema, which obscures\n bony detail. No fractures are seen through the visualized shaft of the humerus\n or proximal shaft of the ulna or radius, although the glenohumeral joint and\n wrist or distal ulna and radius are not included on this study.\n\n IMPRESSION: Severe fracture / dislocation of the elbow.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756370, "text": " 7:08 AM\n CHEST (PORTABLE AP); PELVIS (AP ONLY) PORT Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEWS OF THE CHEST AND PELVIS .\n\n HISTORY: 39 year old female with trauma.\n\n SINGLE VIEW OF THE CHEST: Visualization is limited secondary to the overlying\n trauma board. The lung volumes are low. The cardiac and mediastinal contours\n are unremarkable. There is no evidence of mediastinal widening. The lungs\n are clear. There are no pleural effusions or pneumothoraces. No fractures\n are seen.\n\n SINGLE VIEW OF THE PELVIS: Assessment is limited secondary to the overlying\n trauma board and large amount of soft tissues overlying the upper pelvis.\n There is no evidence of acute fracture or dislocation. There is a marked\n deformity of the right iliac , with heterotopic bone formation laterally.\n Recommend clinical correlation. Appearance suggest this finding is chronic,\n although of uncertain etiology. A central venous catheter is seen overlying\n the right iliac vessels.\n\n IMPRESSION: No evidence of acute injury.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-19 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 756514, "text": " 8:47 AM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: S/P TRAUMA\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post trauma. Patient intubated.\n\n CT OF THE THORACIC AND LUMBAR SPINE WITHOUT CONTRAST; CORONAL AND SAGITTAL\n RECONSTRUCTIONS.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial serial images were obtained through the thoracic\n and lumbar spine without contrast. Coronal and sagittal reconstructions were\n performed.\n\n CT OF THE THORACIC AND LUMBAR SPINE: There is a massive posterior and lateral\n osseous fusion extending from L2 to S1, post-surgical in origin. There are\n multilevel degenerative changes with anterior osteophyte formation and, to a\n lesser extent, disc space narrowing. Degenerative changes are most prominent\n in the lower-thoracic/upper-lumbar spine just above the level of the fusion.\n There is no evidence of fracture or subluxation. Vertebral body height is\n relatively well preserved, with the exception possibly of T9, where there is\n some shortening of the height thought to be chronic. There are no\n paravertebral soft-tissue masses. The dependent portions of the lung\n demonstrate extensive collapse/consolidation. An NG tube and an endotracheal\n tube are present.\n\n IMPRESSION:\n\n 1) Bilateral dependent collapse/consolidation.\n\n 2) Massive posterior and lateral osseous fusion extending from L1 to S1 with\n degenerative changes immediately superiorly. Correlate clinically.\n\n 3) No evidence of acute fracture or subluxation.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756415, "text": " 6:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube exchanges after cuff leak on the old one\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with s/p mvc\n s/p L arm amputation. now sedated and ventilated\n REASON FOR THIS EXAMINATION:\n ET tube exchanges after cuff leak on the old one\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA with left arm amputation. ET tube exchange.\n\n PORTABLE SUPINE AP CHEST, ONE VIEW: Comparison is made to the study of 4\n hours earlier. There is an ET tube 3.7 cm above the carina. The heart is\n normal in size. Allowing for low lung volumes and supine technique, and there\n is no vascular congestion, focal consolidation, or pleural effusion. No\n obvious fracture is identified. There are degenerative changes involving the\n upper lumbar spine.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 756454, "text": " 11:35 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p MVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n s/p MVA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: MVA.\n\n Contiguous axial images without contrast.\n\n There is no mass effect, hemorrhage, displacement of normally midline\n structures or extra-axial accumulation. Ventricles and sulci are not\n remarkable. and white matter are not ideally evaluated because\n examination was obtained on trauma board. Bone images show no definite\n evidence of fracture. The sinuses are opacified consistent with patient\n intubation. There appears to be diffuse edema within the soft tissues\n bilaterally.\n\n IMPRESSION: No evidence of hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-18 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 756455, "text": " 11:36 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MVA and trauma, MVA and trauma\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n MVA and trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Helically-acquired CT images of the lung apex to the pubic\n symphysis with contrast.\n\n CONTRAST: 150 cc of Optiray secondary to inability to obtain an adequate\n history.\n\n CT CHEST WITH CONTRAST: There is an endotracheal tube in place seen to\n terminate above the carina.\n\n The heart size is mildly enlarged. No pericardial effusion is seen. There is\n bilateral basal infiltrate consistent with aspiration. No mediastinal,\n axillary or hilar adenopathy is identified.\n\n LUNG WINDOWS: Lung windows again demonstrate bilateral basal infiltrates\n consistent with aspiration. No pulmonary nodules are identified. The patient\n is intubated with ET tube terminating above the carina.\n\n CT ABDOMEN WITH CONTRAST: The liver demonstrates fatty infiltration,\n otherwise appears unremarkable. The spleen, pancreas, adrenal glands,\n gallbladder and kidneys appear normal. No free fluid or lymphadenopathy is\n identified.\n\n CT PELVIS WITH CONTRAST: The kidneys demonstrate bilateral symmetrical\n contrast excretion. No free fluid is identified. The ureters are seen to\n course to the bladder which is partially filled with contrast. There is a\n Foley catheter in place. There are bilateral adnexal cysts. No free fluid is\n identified.\n\n BONE WINDOWS: Note is made of low lumbar fusion, otherwise no suspicious\n lytic or blastic lesions are identified.\n\n IMPRESSION: No acute traumatic injury is identified.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756635, "text": " 12:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia, s/p trauma LUE amputation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with s/p mvc\n s/p L arm amputation. now sedated and ventilated\n REASON FOR THIS EXAMINATION:\n hypoxia, s/p trauma LUE amputation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post motor vehicle collision and left arm amputation, now with\n hypoxia.\n\n COMPARISON: .\n\n FRONTAL CHEST: In the interval, diffuse bilateral ill-defined cloud-like\n opacities have developed. There are no pleural effusions. The heart is\n upper-normal in size. The mediastinal contours are unchanged.\n\n IMPRESSION: Diffuse air-space opacities bilaterally compatible with pulmonary\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-18 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 756456, "text": " 11:37 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: MVA and trauma, s/p trauma, s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n MVA and trauma\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION:\n 39-year-old woman status post MVA. Intubated.\n\n CT of the cervical spine with coronal and sagittal reconstructions.\n TECHNIQUE:\n CT of the cervical spine without contrast. Coronal and sagittal\n reconstructions.\n\n CT OF THE CERVICAL SPINE:\n The bones are well mineralized without evidence of fracture, dislocation or\n focal area of bone destruction. There is no preveretebral soft tissue\n swelling. The patient is intubated and an NG tube is present. There is\n extensive mucosal thickening with almost complete opacification of the\n maxillary, ethmoid and sphenoid sinuses. Fluid levels are noted within the\n sphenoid sinuses and possibly maxillary sinuses. The visualized brain and soft\n tissues are grossly unremarkable.\n\n CORONAL AND SAGITALL RECONSTRUCTIONS: Reconstructions are consistent with the\n above findings, without evidence of fracture or subluxation. No prevertebral\n soft tissue swelling is identified.\n\n IMPRESSION:\n 1. No evidence of fracture or subluxation.\n 2. Extensive sinus mucosal disease as described above.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756679, "text": " 6:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF ? resolving\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with s/p mvc\n s/p L arm amputation. now desating after extubation on roomair previous CXR\n shows probable CHF and patient improving on lasix\n REASON FOR THIS EXAMINATION:\n CHF ? resolving\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reassessment in patient with heart failure.\n\n COMPARISON: .\n\n AP CHEST: In the interval since the prior study, there is decrease in the\n extent and intensity of the diffuse bilateral air space opacification\n consistent with partial resolution of heart failure. The heart size is within\n normal limits, and the mediastinal and hilar contours are normal. There are\n no pleural effusions and no pneumothorax.\n\n IMPRESSION: Interval improvement in pulmonary edema consistent with resolving\n heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756407, "text": " 2:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with s/p mvc\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA. Intubated.\n\n SUPINE AP CHEST, ONE VIEW: Comparison is made to study of 6 hours earlier.\n The patient has been removed from the trauma board. There is an ET tube 5.6\n cm above the carina. The heart size is within normal limits allowing for\n technique. The lung volumes are low. There is no obvious consolidation, CHF,\n pleural effusion, pneumothorax, or fracture identified.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2123-12-17 00:00:00.000", "description": "Report", "row_id": 1508284, "text": "MICU/SICU Nursing Progress Notes\n36 year old female admitted from OSH with drug OD.\n\nPast Medical history: Asthma; hepatitis C; kidney stones; anxiety disorder and personality disorder; H/O pneumonia; chronic loow back pain; cocaine and heroine abuse (last use ~1year ago); H/O OD's.\n\nAllergies: cocaine, ultram -> seizures, ?PCN -> yeast rash\n\nPt was found unconscious by a friend and left at an OSH following a drug OD of klonipin and trazodone. She was intubated, given charcoal, thiamine, narcan, glucose and IVG. Her toxic screen was positive for poiates and benzo's. She was then transported to for treatment.\n\nROS: Resp: Pt arrived intubated on AC 500x12, Peep 5, FiO2 40%. She was on propofol for the transport and she was placed on 10 mcg/kg/min but quickly weaned to off by 0030 in order to facilitate her extubation. It was attempted to place her on PSV twice but even though she appears to be wakening up, she continues to have significant resp failure requiring mechanical ventilation. The last attempt was 0400 and she was placed on SIMV 500x8, Peep 5, FiO2 40%. She was not overbreathing the vent and continue was very somulant to ~0600 when she was successfully changed to PSV 10/ Peep 5.\n\nneuro: on arrival she was not responsive to pain due to the propofol received during transport. Since she has been awake off and on. She will attempt to sit up in bed but she followes commands. She has remained very somulant. She is restrained with bilateral soft wrist restaints to prevent self extubation. When she is extubated she will need 1:1 sitters for suicide precautions.\n\nCardiac: B/P 95/49-108/50's, HR 70's. Her phos was low she she is receiving 15mmol's of Kphos.\n\nGI: She has an OGT in place that is filled with charcoal. Her abdis soft and non tender with (+) bowel sounds. No stool yet.\n\nGU: initially she had 625cc of clear yellow urine but her U/O was marginal, U/O 10-15cc/hr. She is receiving D51/2 NS at 100cc/hr.\n\nID: She was initially hypothermic but has warmed to 98.8 PO. She is not on any antibotics.\n\nSkin: She has an abrasion on the left temporal area that she had sustained prior to .\n\nSocial: Her father called, consent was obtained. His Phone # is .\n\nPlan: continue weaning heading for extubation, 1:1 stitters when extubated, hydration, monitor U/O.\n" }, { "category": "Nursing/other", "chartdate": "2123-12-17 00:00:00.000", "description": "Report", "row_id": 1508285, "text": "Addendum\nPt awoke while blood was being taken. She was trying to talk and seems oriented. She was extubated and started talking immediately following extubated and has been explaining the circumstances of her pre-hospitalization.\n" }, { "category": "Nursing/other", "chartdate": "2123-12-17 00:00:00.000", "description": "Report", "row_id": 1508286, "text": "Nsg Progress Note 0700-1900\n\nCV - Hemodynamically stable. Afebrile. IVF heplocked as pt taking po's well. Both IV's dc'd without any problems.\n\nResp - Initially required O2 via NC while sleeping but over the course of the day - pt sleeping well with no drop in O2 sats. Sats maintained over 96% consistently. BS cl bilat. Required one albuterol tx for wheezing with excellent results.\n\nGI- Tolerating PO's very well. No c/o nausea. No BM.\n\nGU - Dc'd foley in am - voiding qs when up to commode. Initially c/o of burning but now states it feels fine. Urine is cl yellow.\n\nOrtho - left arm cast dry and intact. No swelling noted and pt has not c/o pain or discomfort. Left temporal abrasion is clean and dry.\n\n Pt seen by , Social worker and psych today. All felt that pt's story was very believable and she was not attempting to commit suicide. Pt is manic at this point and very talkative and happy. She states she has not felt this good in weeks. Plan to restart psych meds and she will be connected with a psych person in her area who will be able to follow her.\n\nSocial - Father in to visit and very supportive and appropriately concerned. Has been on the phone with multiple family members and boyfriend many times during the day. Social worker did speak with pt concerning possible violence at home but pt does not feel threatened at this point.\n\nPlan - Pt can be discharged from MSICU if she can find a ride home.\nShe has been given names of people to call once she is home.\n" }, { "category": "Radiology", "chartdate": "2123-12-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 844932, "text": " 9:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman found unconscious, now intubated.\n REASON FOR THIS EXAMINATION:\n evaluate for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:38 PM\n No hemorrhage or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old woman found unconscious.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: None.\n\n HEAD CT:\n\n FINDINGS: There is no acute intra or extraaxial hemorrhage. The ventricles,\n cisterns, and /white matter differentiation are unremarkable. There is no\n mass effect and no shift of normally midline structures.\n\n The osseous structures, mastoid air cells, and visualized paranasal sinuses\n are unremarkable.\n\n IMPRESSION: No acute hemorrhage or mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2123-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844937, "text": " 10:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with pta intubation\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to earlier study of . There is an endotracheal tube with tip at the thoracic inlet. A\n nasogastric tube is present which is coiled within the stomach. The\n cardiomediastinal silhouette is within normal limits. There is a moderate\n sized effusion which is layering at the right apex. There are no focal\n consolidations in the right lung. There is minimal linear atelectasis at the\n left lung base.\n\n IMPRESSION:\n 1) Endotracheal tube properly positioned with tip at the thoracic inlet.\n\n 2) Moderate sized right pleural effusion.\n\n" }, { "category": "ECG", "chartdate": "2123-12-17 00:00:00.000", "description": "Report", "row_id": 262318, "text": "Sinus rhythm\nMinor anterolateral ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2123-12-16 00:00:00.000", "description": "Report", "row_id": 262319, "text": "Sinus bradycardia\nLateral ST flattening is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2123-12-16 00:00:00.000", "description": "Report", "row_id": 262320, "text": "Sinus rhythm\nLateral T wave changes are nonspecific\nSince previous tracing of , QT-c is shorter\n\n" } ]

[ { "category": "Radiology", "chartdate": "2152-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948961, "text": " 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrates.\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ABF, resp compromise now trached on trach mask with\n increasing secretions, increasing WBC ct.\n REASON FOR THIS EXAMINATION:\n eval for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Patient with ABF with increasing secretion, increasing white\n blood count.\n\n Comparison is made with prior study performed a day before.\n\n FINDINGS: Cardiac size is normal. There is no pleural effusion or\n pneumothorax. Endotracheal tube tip lies against the left lateral wall of the\n trachea. Left subclavian vein catheter tip is in the upper SVC. Improved mild\n pulmonary edema.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-14 00:00:00.000", "description": "Report", "row_id": 1531445, "text": "CONDITION UPDATE:\nD/A: T MAX 97.9\n\nNEURO: ALERT, APPEARS TO UNDERSTAND WHAT IS BEING SAID, HOWEVER VERY INCONSISTENTLY FOLLOWS COMMANDS. DID FOLLOW ALL COMMANDS FOR FAMILY WHEN THEY WERE VISITING. NOT COMBATIVE OR AGITATED. NODS HEAD NO TO PAIN. MAE. OOB TO CHAIR VIA .\n\nCV: HR 70'S-80'S NSR WITH FREQUENT PVC'S. IN AFTERNOON, PT HAD X4 BEAT RUN OF V-TACH. ELECTROLYTES CHECKED, K+ 4.1, MAG 2.0, CALCIUM 7.6. EKG DONE, REVIEWED BY DR. . ABP ~ 145/65. FLUID BALANCE MN-1800 + ~ 1000 CC'S.\n\nRESP: LS COARSE. PT WITH STRONG COUGH AND EXPECTORATED WHITE THICK SPUTUM. RESPIRATORY THERAPIST ADMINISTERED FREQUENT NEBULIZERS AND TRACH SUCTIONING. PT ON TRACH COLLAR @ 40% WITH O2 SATS ~100%.\n\nGI: TUBE FEEDS RESTARTED @ 30 CC/HR WITH NO TUBE FEED RESIDUALS. ABDOMEN SOFTLY DISTENDED. + BS. NO BM.\n\nGU: FOLEY-BSD WITH AMBER URINE.\n\nSKIN: VAC DRESSING REMOVED FROM GROIN AND DSD APPLIED.\n\nSX: FAMILY VISITED.\n\nR: AFEBRILE, RESP STATUS IMPROVING WITH AGRESSIVE PULMONARY TOILET, NEURO STATUS IMPROVED.\n\nP: CONTINUE AGGRESSIVE PULMONARY TOILET. CONTINUE TO EVALUATE NEURO STATUS, GI STATUS. CONTINUE TO MONITOR VITALS, PAIN. PT . PT AND FAMILY SUPPORT. NUTRITION.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-15 00:00:00.000", "description": "Report", "row_id": 1531446, "text": "Resp Care\nPt remains trached on cool aerosol mist @ 40%. MDI's given. Tobra neb given. Trach care done, pt suctioned for small amt of thin white.\nNo other changes noted.\n" }, { "category": "Radiology", "chartdate": "2152-02-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 947767, "text": " 1:05 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? line position, ? pneumothorax\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass now s/p L CVL line placement\n REASON FOR THIS EXAMINATION:\n ? line position, ? pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: at 6:33 a.m.\n\n INDICATION: Left vascular catheter placement.\n\n Left subclavian vascular catheter has been placed, with tip terminating in the\n superior vena cava. Tip appears to be directed laterally towards the lateral\n wall of this vessel. There is no pneumothorax. Interstitial edema has\n progressed in the interval, and there is worsening left retrocardiac opacity\n and adjacent left pleural effusion. Moderate partially layering right pleural\n effusion is without change.\n\n IMPRESSION:\n 1. Left subclavian vascular catheter, position as described, with no\n pneumothorax.\n 2. Worsening interstitial edema and slight increase in left pleural effusion,\n but stable right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946562, "text": " 8:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass being treated for hospital acquired\n pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hospital-acquired pneumonia.\n\n PORTABLE AP CHEST.\n\n COMPARISON: .\n\n Multifocal areas of consolidations are noted in both lungs, not significantly\n changed since prior radiograph. A moderate right pleural effusion and right\n bilateral retrocardiac atelectasis persist. The right IJ catheter tip is at\n the cavoatrial junction.\n\n IMPRESSION: No significant change since prior radiograph.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-30 00:00:00.000", "description": "Report", "row_id": 1531387, "text": "focus update note\nplease see flowsheet for details\n\npt lethargic, not following commands, alternating between yelling out and sleeping, pupils equal and reactive, pt localizing pain. abg sent and paco2=72 , decision made to intubate pt, pt intubated without difficulty, aline placed, CXR revealed right lower lobe collapse, pt bronched with minimal secretions suctioned,pt found to be in bronchospasm, sputum sent, propofol initiated for sedation -pt became hypotensive, cardiac enzymes cycled, EKG unchanged, levophed .06 mcq/kg/min started and 1 liter bolus lr given. sbp increased to 110-120s. will continue with serial abgs to follow co2 closely\n\npt continues on heparin gtt , with serial PTT draws q 6 hours, currently running at 900u/hr.\n\ngu/gi, pt abd distended- primary/icu team aware, will monitor and guiac stool, will notify team if UO decreased below 30cc hr.\n\nabd : vac dressing and left fem dressing and midline abd dressing are all intact without drainage, dopplerable pulses in bilateral lower extremities\n\nplan; continue to cycle cardiac enzymes, head Ct at 1800 tonight, levophed gtt to maintain map > 60, monitor neuro status. moniotr abd distention\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-31 00:00:00.000", "description": "Report", "row_id": 1531388, "text": "Respiratory Care Note:\n Patient on PSV of % with good ABGs this am. Plan to wean FIO2 as tolerated. BS diminished RLL. Suctioned for thick whitish secretions and receiving albuterol and atrovent MDIs Q4 with good effect.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-31 00:00:00.000", "description": "Report", "row_id": 1531389, "text": "focus hemodynmics\ndata: neuro: sedated on versed 1.5mg /hr. withdraws to painful stimuli. at times when turning in the bed , pt attempts to sit up in the bed. moves head back and forth on pillow. moves exteemities on the bed.\n\nresp: suctioned for yellow sputum. multiple abg/s sent. on cpap60% 10/10. 02sats 91=96%. abg this am (most recent) 7.44-51-110-36. breath sounds course.\n\ncardiac: remains in nsr. 80's no ectopy seen. k 3.8 20meq kcl x1 given. magnesium 2.6, heparin gtt infusing. ptt q6hrs. infusing at 110-units/hr. hct 29.7\n\ngu: foley patent and draining yellow urine.\n\ngI abd firmly soft and distended. stool x1. tpn infusing. npo. hypoactive bowel sounds.\n\naction: suctioned prn. labs as ordered. tpn infusing. k repleted. on iv pipercillin and vano. wbc 19.9 versed gtt for sedation.heparin gtt with q6 ptt. update family.\n\nresponse: monitor closley.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-31 00:00:00.000", "description": "Report", "row_id": 1531390, "text": "resp care - Pt remains intubated and on PSV. No vent changes made this shift. BS mostly clear. MDIs given as ordered. ABG shows compensated resp acidosis. Weaning planned.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-01 00:00:00.000", "description": "Report", "row_id": 1531393, "text": "Respiratory Care:\n He continues on PSV of and 60%. BS bilat, diminished. Received albuterol and atrovent Q4. Suctioned for small to med amounts of pale secretions. He appeared comfortable t/o shift with good oxygenation. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-01 00:00:00.000", "description": "Report", "row_id": 1531394, "text": "1900-0700 Addendum NPN\nPTT 72.5, Dr aware. Heparain gtts decreased to 1050 units/hr. Next PTT at 1000. ABG ph 7.30, paCO2 66. Dr aware. Remains on CPAP , breathing comfortably. No vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-03 00:00:00.000", "description": "Report", "row_id": 1531402, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support. PSV decreased to 5 cm. Last abg results on 10 cm PSV determined a compensated respiratory acidemia with adequate oxygenation.\n\nRSBI = 30.3 on 0-PEEP and 5 cm PSV. SBT to begin at 0630.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-03 00:00:00.000", "description": "Report", "row_id": 1531403, "text": "update\nSee Carevue for specifics\n\nNEURO: Sedated most of day d/t intubation and CVL placement. Sedation held after line placed for extubation. Still lethargic. Will open eyes to voice/stimuli but does not follow commands. Purposeful movements, lifts and holds all extremeties. PERRL.\n\nCV: NSR. SBP WNL. A-line sharp. IJ central line d/c'd & tip sent for cx. Multi lumen placed in L sub clavian. Cleared via chest xray. Heparin gtt held from 0800-1600 d/t line resiting. Currently at 1100 units/hr and last PTT theraputic. Carotid U/S done.\n\nRESP: Extubated at 1600. Tolerating well. Post-extubation ABG ok.\n\nGI: TF held most of day. Started up again at 1600 at 20/hr. +BS. No stool.\n\nGU: Foley draining 100-250 cc/hr. Urine yellow, clear.\n\nSkin: Abd incision approximated & healing. No dsg. R groin dsg intact. L groin incision sutured, CDI, no dsg.\n\nSocial: Daughter called twice during day.\n\nPlan: Monitor overnoc for respiratory issues. ? check another ABG. Monitor coags and adjust heparin gtt as ordered. Monitor mental status and provide interventions for agitation prn.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-03 00:00:00.000", "description": "Report", "row_id": 1531404, "text": "Resp Care\n\nPt received on PSV 5/5 tol well and was extubated this evening after successful SBT this morning. BS clear to slightly course sxing for small amts of thin white secretions t/o shift. Cuff leak noted prior to extubation with good cough noted. ABG post extubation WNL with good oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-04 00:00:00.000", "description": "Report", "row_id": 1531405, "text": "NURSING\n VSS, NSR, NO ECTOPY. EXTUBATED YESTERDAY AT 4 PM, RESPIRATORY STATUS STABLE UNTIL 0400 WHEN RR INCREASED TO 30'S, LUNGS WITH MORE COARSE BREATH SOUNDS. NASAL TRUMPET PLACED, NASOTRACHAEL SUCTIONED FOR SMALL AMOUNTS CLEAR SPUTUM. COUGHED AND RAISED DURING THE PROCESS, LUNGS IMPROVED AFTER. ABG DRAWN PRIOR TO SUCTIONING WITH PAO2 IN THE 60'S. FACE TENT CHANGED TO HIGH FLOW MASK AT 60%, WILL RECHECK ABG IN 30 MINS.SEE CARE VUE FOR FULL SPECIFICS.\n RMEAINED FAIRLY SOMNOLENT OVERNIGHT, NEVER FULLY WAKING. MUMBLING INCOHERENT PARTS OF WORDS, NOT FOLLOWING COMMANDS. REMAINS RESTRAINED.SOFT WRIST RESTRAINTS ON UPPER EXTREMITIES. CONTINUES TO THRASH IN THE BED ON OCCASION.WILL ATTEMPT TO PULL OUT TUBES WHEN RESTRAINTS OFF.\n CONTINUES ON TUBE FEEDS AT 20/HR. FOLEY WITH GOOD AMOUNTS URINE OUTPUTS/HR. RESPONDED WELL TO LASIX DOSE AT 2200.\n CONTINUE TO MONITER HEMODYNAMICS, RECHECK PTT AT 1100. FREQUENT PULMONARY TOILETING.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-04 00:00:00.000", "description": "Report", "row_id": 1531406, "text": "Resp. care note - Pt. reintubated for resp. distress. Pt, intubated with # 8 OET 23 at the lip, placed on the vent at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-01 00:00:00.000", "description": "Report", "row_id": 1531395, "text": "condition update\nplease see carevue for specifics;\nneuro: midaz gtt d/c'd this am for wake up. Received 3mg midaz. for bronch. Precedex started this afternoon. Currently, pt arouses to noxious stimuli, does not follow commands, mae, pupils are equal and reactive.\ncv: nsr without ectopy. sbp 90's-120's, peripheral pulses are palpable/dopplerable (unchanged). heparin gtt continues, ptt within goal of 50-70. LENI's obtained at bedside.\nresp; bronch today, pt tolerated well. Abg's monitored, co2 remains elevated - sicu team is aware. No vent. changes.\ngi: abd soft distended, bs are absent and residual checked this am - 400cc bilious fluid was aspirated - sicu team was notified and tf were\nheld. kub obtained - dobhoff is in stomach (not post pyloric). no bm this shift.\ngu: foley draining adequate amts. clear amber urine.\nendo: no ssri coverage necessary.\nID: vanco/zosyn restarted.\nplan: cont. precedex, titrate to sedation, rsbi and sbt in am, ? extubate in am, continue pulmonary toileting, hold tf for now.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-01 00:00:00.000", "description": "Report", "row_id": 1531396, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 5/5 tol well with stable minute ventilation on present settings. BS dim/slightly course sxing for small amts of thick tan secretions. ETT secured/patent. VD/VT measured at 74% with improved ABG upon removal of swival adapter. MDIS given x3 with good effect noted. Will cont with vent support with possible extubation tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-02 00:00:00.000", "description": "Report", "row_id": 1531397, "text": "1900-0700 NPN\nSee Careview for details:\n\nMore alert overnight but very aggitated with stimulation. Presedex restarted at .2mcg/kg/min. Not following any commands but moving all extremities, upper extremities localizing with good strength. Fentanyl 25mcg given once for discomfort with turing/repositioning. TMAX 100.1. Tele SR occasional PVC's HR 60-70's. Blood pressure 110-130's, occasionally down to 90's but resolves without intervention. Heparin @ 1050 units/hr, PTT this am 48.5, gtt increased to 1100units/hr. Lungs coars throughout, frequent sxn for moderate amt thin white secretions. Abd soflty distended, hypoactive bowel sounds. Remains NPO. Adequate urine output. No breakdown noted. Plan to wean from vent as tolerated, monitor neuro status, monitor hemodynamics and respiratory status maintain saftey and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-02 00:00:00.000", "description": "Report", "row_id": 1531398, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a compensated respiratoru acidemia with adequate oxygenation on the current settings. SX'd for copious secretions.\n\nNo RSBI measured due to level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-04 00:00:00.000", "description": "Report", "row_id": 1531407, "text": "STATUS\nD: LETHARGIC SLOW TO AROUSE..SAT'S DROPPING>>MIN COUGH REFLEX WITH NT SUCTIONING..HEPARIN GTT @1200U\nA: VAC DSG RT GROIN DC'D..CONTINUES TO OOZE LGE AMT SEROUS FROM SITE.. INCT LOOSE BROWN STOOL>>VOMITED WHEN PLACED ON SIDE TO CLEAN..FLEXI SEAL PLACED..TF'S OFF..DROPPING SAT'S>>MIN COUGH REFLEX..VOMITED AGAIN & ? ASPIRATED>>INTUBATED #8 ET TUBE INITIALLY @ 21 @ LIP X-RAY SHOWED OUT TO FAR PUSHED IN TO 23 @ LIP>>DROPPED BP GIVEN 500CC N/S FLUID BOLUS X2 & NEO GTT STARTED..NG INSERTED FOR LGE AMT BILIOUS>>FT DC'D ADQUATE HUO'S\nR: CONTINUES WITH POOR PULMONARY STATUS\nP: ? TRACH NEXT WEEK..WEAN NEO AS TOL TO KEEP SBP > 100/..KEEP FLUID BALANCE NEG..MONITOR NEURO STATUS CLOSELY..LABS PER HO..PTT Q6H & AFTER HEPARIN GTT CHANGES\n" }, { "category": "Nursing/other", "chartdate": "2152-02-06 00:00:00.000", "description": "Report", "row_id": 1531412, "text": "NPN\nPlease see CareVue for specifics.\nNEURO: Agitated. PERRL. Not following commands. At times pulling at restraints and attempting to sit up when suctioned. Ativan 1mg Q2H w/mod effect. Fentanyl PRN administered x2 w/hypotensive episodes to SBP80's immediately following. MD' and notified. Tmax 101.1ax. No action taken per SICU HO as pt pan cx 2/10AM. Presently 100.9ax.\n\nCV: NSR. @0030 Pt w/SVT to 150's followed by RAF and tachy/brady epidsodes. MD notified and at bedside. Lopressor IVP administered w/pt returning to NSR. CE's initiated, EKG obtained, labs and ABG drawn. Fluid bolus x2 for periods of hypotension. Presently +~600for 24H. Edematous hands L>R noted. Groin staples S/P aortobifem pink w/copious amts serous fluid draining from right groin. MDs aware. No changes in Heparin gtt this shift-@1150Units/hr. Most recent PTT 55(goal50-70). PPP. Routine CXR this AM.\n\nRESP: Intubated. CPAP+PS. FiO2 50%. PEEP decreased to 8 with acceptable ABG's following change. ETT rotated. LS coarse w/occas insp wheeze noted in LUL. MDI's by RT per schedule. Sxn for small to moderate amts thick tan secretions. Oral sxn for increased secretions as well. Frequent oral care performed.\n\nGI: NPO. TFw/lipids infusing. NGT w/large amts bilious drainage. 1050cc ouput this shift. SICU and Primary teams notified. NGT replaced due to falling out. BS+. Abd slightly distended. Flexiseal intact. Nystatin cream applied to red rash in groin and buttocks.\n\nGU: Patent foley draining amber urine.\nPLAN: Monitor CV, maintain Hep Gtt, monitor for increased agitation, aggresive pulmonary toileting, change dsg to right groin frequently as needed, maintain skin integrity.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-08 00:00:00.000", "description": "Report", "row_id": 1531423, "text": "STATUS\nD: AGITATED AT TIMES..DOESN'T FOLLOW COMMANDS MOVES ALL EXTREM'S\nA: TO O.R. FOR #8 TRACH & PEG..TOL PROCEDURE WELL..NOT REVERSED BUT RESPONDING BY 1600>>PLACED BACK ON ORIGINAL VENT SETTINGS WITH GOOD SAT'S & RESP RATE..SUCTIONED FOR COPIOUS AMT THICK WHITE..PEG TO GRAVITY DRAINING BILIOUS..SITE C&D..OOZING SM AMT BLOODY FROM AROUND TRACH SITE..RT GROIN VAC DSD DRAINING SM/MOD AMT SEROUS..LF GROIN D&I RASH OVER PERI AREA..ADQUATE AMBER URINE..NO STOOL\nR: STABLE\nP: WEAN VENT AS TOL..RESTART TF'S @ 1400 PER HO ORDERS..GOOD PULMONARY TOILET..LABS PER HO\n" }, { "category": "Nursing/other", "chartdate": "2152-02-09 00:00:00.000", "description": "Report", "row_id": 1531424, "text": "Resp Care\nPt. remains trached on PSV overnight. IPS weaned to 10 this morning. Pt. continues to be tachypneic at times RR 25-35bpm. VT's 350-650cc with avg MV 10-15L.\nBS: coarse bilat. sxn'd for sm-mod. yellow bld. tinged.\nabgs:mild resp. acidosis with adequate oxygenation.\nPlan: Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-09 00:00:00.000", "description": "Report", "row_id": 1531425, "text": "FOCUSED NURISNG NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: Trach/ventilated. Awake, does not make eye contact, seems to look through people. Flails around when agitated attempting to place self in full side-lying position or prone- does not follow commands. PERRL, 2-3mm. When turned on side as far as possible, pt calms down considerably, fentanyl for facial grimace and nursing care procedures for sedation.\n\nRESP: Surgical trach , site patent, small amts serosanguinous and gelatinous clear drainge from site. Ventilated on CPAP w/ PS 10, PEEP 5 FiO2 40%- RR 20-26, SPO2 93-98%. recent ABG shows mild resp acidosis. Suctioned frequently for thick/tan secretions. Lungs with scattered rhonchi/coarse bilaterally.\n\nHEMODYNAMICS: HR 70-90s, NSR, no ectopy on Lopressor 5mg q4hr ATC. SBP 95-140s, incr to 160s when agitated. Adequate u.o., amber. Fluid balance largely negative, SICU team aware. TPN at 62ml.hr, otherwise no maintenance fluids. Moderate outputs from g-tube and right groin vac. No sx bleeding. HCT stable. K+ 4.9.\n\nID: Tmax 101- SICU resident aware. No cultures at this time. Note yeast present in previous sputum and urine cx. Previous blood cx negative. Left groin incision staples intact, site firm/indurated, weeping serous fluid in small amt. Diffuse yeast-like rash to perineum and buttocks. treated with frequent skin care and nystatin cream/OTA.\nOn Flagyl/Vanco as ordered.\n\nGI/METABOLIC: NPO. New PEG tube to gravity drainage, total 700ml this shift. Abdomen softly distended, bowel tones hypoactive then absent, no n/v. Pt prefers flexed knee and prone side-lying/prone position best, ?alleviating abd pain. Glucoses wnl, no RISS coverage needed.\n\nPLAN OF CARE: Monitor neuro/resp status closely. Wean vent per SICU team? Neuro or psych consult if sedatives can be tapered down now that pt has trach. Pt appears to continue to need pain control, location unclear, Fentanyl therapeutic. TPN. Start TF via PEG as 1400 today, monitor for tolerance. Aggressive skin care, VAP prevention measures.\nAntibiotics, monitor for sx infection.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-09 00:00:00.000", "description": "Report", "row_id": 1531426, "text": "Respiratory Care Note\nPt received on PSV 10/5 as noted. BS coarse with expiratory wheezes bilaterally. Pt suctioned for large amts thick secretions. PS weaned to 5 - pt agitated and became tachypneic from 32 to 43 with VT 500-600. PS increased back to 10 and given Ativan RN with relief. Pt transported to CT Scan for chest abdomen and pelvis - results pending. Plan to continue on PSV at this time and place pt on trach mask trials in the am.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-05 00:00:00.000", "description": "Report", "row_id": 1531408, "text": "NURSING\n VSS, SBP REMAINS IN THE 98-110 RANGE. CONTINUES ON NEO, CURRENTLY AT .75 MCGS. NSR, NO ECTOPY. AFEBRILE OVERNIGHT DESPITE ALMOST A 10 POINT BUMP IN HIS WBC'S. CVP 9-10. NO MIANTENANCE IVF INFUSING, TPN RUNNING, TUBE FEEDS REMAIN OFF.\n ABG'S CONSISTENT WITH ACIDOSIS WITH PAO2'S IN THE 60'S AT THE BEGINNING OF THE SHIFT. OVERBREATHING THE VENT, ON AC WITH RATE OF 30-34. ABG'S RECHECKED. GIVEN SOME SEDATION, FENTANYL, AND PEEP INCREASED WITH RESULTING IMPROVEMENT OF ABG'S AND OXYGENATION STATUS.SUCTIONED FOR MODERATE AMOUNTS CLEAR SPUTUM.\n NGT DRAINING LARGE AMOUNTS BILIOUS DRAINAGE. FOLEY WITH QS URINE OUTPUT.\n DRESSING ON RIGHT GROIN SITE STILL DRAINING LARGE AMOUNTS SEROUS DRAINAGE. DSD AND SOFT SORB PAD CHANGED FREQUENTLY. CONTINUES TO HAVE YEAST ON SKIN IN GROIN AND PERIANAL AREA. NYSTATIN CREAM APPLIED FREQUENTLY TO SKIN.\n CONTINUE TO MONITER HEMODYANMICS, RESPIRATORY STATUS. FOLLOW LABS, RECHECK POTASSIUM DUE TO LASIX. FREQUENT CHEST PT AND PULMONARY TOILET.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-05 00:00:00.000", "description": "Report", "row_id": 1531409, "text": "BS coarse crackles; no change with MDI's. FiO2 and PEEP weaned without incident, followed by transition to CPAP. Will monitor and decrease PSV when appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-06 00:00:00.000", "description": "Report", "row_id": 1531413, "text": "Nursing Progress Note\nSee Carevue for specifics\n\nEvents: CT of abdomen with contrast done. Pt tolerated procedure well. Returned to SICU at 1400-pt very agitated upon return to unit. Given 1 mg Ativan and 25 mcg Fentanyl. SBP decreased to 80's-given 500 cc LR bolus with good effect. aware. SBP rebounded to 120's.\n\nNeuro: Arouses to painful stimuli. PERRL 3 mm bil. Localizes painful stimuli x 4 ext's. Agitated at times-given 1 mg Ativan q 2 hours prn with good effect.\n\nCV: NSR. No ectopy. HR 60's-70's. BP 100-117/50's. Lopressor dose increased to 25 mg po tid. Dose held at 1400 secondary to low BP. compression sleeves on. Heparin gtt at 1150 units/hr. PTT 82 at 0800. Gtt decreased to 1100 units/hr. Off at 1200 for potential paracentesis. Gtt restarted at 1400 after procedure-dose 1100 units/hr. next PTT due at 20:00. Afebrile.\n\nResp: Vented CPAP w/PS 8 + 15. 50% FIO2. Sats 97-100%. Suctioned q 1 hour for large amounts thick tan-white secretions. MDI's administered by RT as ordered. Impaired gag reflex. Productive cough. LS coarse throughout.\n\nGI: Abdomen softly distended. +BS. NGT right nare to CLWS draining large amounts bilious drainage. TPN continuous at 62.5 cc/hr. Flexiseal in place draining liquid brown stool.\n\nGU: foley draining CYU.\n\nSkin: Midline abdominal incision approximated. C/D/I. Left femoral graft site with staples C/D/I. right femoral graft site with staples leaking copious amounts serous fluid-covered with gauze sponges and softsorb-changed q 1-2 hours. Team aware. Red rash perineum-Nystatin applied as ordered. Left hand slightly edematouskept elevated.\n\nEndo: FBS well-controlled with RISS.\n\nLabs: 2nd and 3rd set of CK's drawn and sent. WNL. K 4.2. Vanco trough 17.\n\nPlan: Tracheostomy tomorrow. Family aware. continue monitor Vs, hemodynamics, resp status, labs.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-06 00:00:00.000", "description": "Report", "row_id": 1531414, "text": "BS coarse crackles, rhonchi; no change with MDI's. Suctioned for mod amount thick tan secretions. CT of abdomen and pelvis today. Results unchanged; no new foci. Trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-09 00:00:00.000", "description": "Report", "row_id": 1531427, "text": "FOCUS; STATUS UPDATE\nDATA;\nPT TO VOICE BUT NOT FOLLOWING ANY COMMANDS. MOVES ALL EXTREMITIES WITH STRENGTH. DOES NOT TRACK SPEAKER OR ATTEMPT TO COMMUNICATE.\n\nLUNGS COARSE THROUGHOUT, AT TIMES EXP. WHEEZING NOTED. MDI INHALERS PER RESPIRATORY THERAPY WITH EFFECT. UNABLE TO TOLERATE WEANING OF PS THIS AM DUE TO DESAT AND INCREASED RESP RATE TO 41, AND BP TO 200'S SYSTOLIC.\n\nCT ABD, CHEST AND PELVIS DONE THIS AFTERNOON. SEDATED WITH PROPOFOL FOR PROCEDURE WITHOUT SIGNIFICANT HYPOTENSION. RESULTS PENDING. PEG TO GRAVITY DRAINAGE-TUBE FEEDS RESTART SUSPENDED DUE TO LARGE OUTPUTS TODAY. CONTRAST GIVEN VIA PEG FOR CT SCAN. LARGE AMOUNTS OF CONTRAST DRAINAGE NOW POST PROCEDURE AS WELL AS LARGE AMOUNTS LIQUID STOOL. BICARB DRIP ALSO HUNG D/T IV CONTRAST.\n\nPLAN:\nCONTINUE CURRENT PLAN OF CARE. WEAN TO TRACH COLLAR IN AM.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-10 00:00:00.000", "description": "Report", "row_id": 1531428, "text": "Resp Care\nPt. remains trached on PSV w/o change overnight. Vt's 450-550 with avg. MV 10-14lpm. Tachypneic in low 30's at times.\nBS: coarse bilat. R>L. Sxn'd occ. for thick yellowish.\nabgs:within acceptable parameters.\nPlan: Would recommend trach mask sprints.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-11 00:00:00.000", "description": "Report", "row_id": 1531433, "text": "NPN\nPlease see CareVue for detailed assessments.\n\nNEURO: No change. Continues to be inconsistent w/following commands. Impaired fine motor skills noted in BUE. Ativan x2 for increased anxiety.\n\nCV: SR w/PVC's. HR and SBP stable. Lopressor per schedule. Hydral x1 for SBP >140 w/result of SBP to 110's. Potassium and Magnesium repletions this AM. Hct stable. Plt 454 from 410 previous day. WBC 19.3.\n\nRESP: Tol trach collar until ~2300. Tachypneic and tachycardic. Pt. noted to have labored breathing and wheezes throughout. Ambu and sxn followed by neb w/minimal result. Pt. placed back on CPAP+PS. Please see CareVue for specifics. ABGs wnl. Sxn for small amts tan thick secretions. Strong productive cough. Pt. continues to refuse oral care. MDI by RT. AM RSBI 53.\n\nGI: NPO. Cont on TPN w/lipids. PEG clamped - residuals checked. Erythromicin for motility. Abd soft, distended, and tender to palpate LUQ. FIB intact w/loose brown stool noted.\n\nINTEG: No improvement on rash to peri area. Miconazole powder applied.\nPLAN: Monitor neuro status, CV, aggressive pulm.toilet.,monitor PEG residuals, ?start TF, maintain safety.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-11 00:00:00.000", "description": "Report", "row_id": 1531434, "text": "resp care - Pt, trached with #8 Portex, was placed on .50 TM this AM and has remained off the vent for this shift. Pt was suctioned frequently for moderate to copious thick white secretions. BS were coarse with scattered wheezing t/o. MDIs were given as ordered. Increased time with TM is planned.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-07 00:00:00.000", "description": "Report", "row_id": 1531415, "text": "Resp: pt on psv 15/8/50%. Ett #8, 23 @ lip. BS are coarse bilaterally. Suctioned for copious amounts of thick tan secretions. MDI's admistered as ordered alb/atr with no adverse reactions. AM ABG 7.40/45/99/25. RSBI=66. Will continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-07 00:00:00.000", "description": "Report", "row_id": 1531416, "text": "NPN\nPlease see Carevue for specifics\nNEURO: Uncooperative and combative at times. Ativan 1mg PRN w/minimal effect. PERRL 2-3mm and reactive. MAE. Very strong-continous attempts to pull at restraints ant ETT. Not following commands. Tmax 100.8ax.\n\nCV: SR most of shift w/episode of hypertension and tachycardia w/agitation. Ativan&Fent w/minimal effect. Lopressor 5mg IVP w/HR returning to SR 80's and SBP to 80's. Fluid boluses w/effect. Please see carevue for specifics.\n\nRESP: Remains intubated CPAP+PS15 5PEEP FiO2 50%. Briefly on MMV during noc for better ventilation. LS coarse throughout w/occass. insp.wheezes. Frequent sxn for mod amts thick tan secretions. CPT performed. Bleeding gums-frequent oral care performed.\n\nGI: NPO. NGT w/~ 1 Liter bilious output overnoc. BS+. FIB out during noc. No stools this shift.\nGU: UOP changed from amber to color. Teams notified.\nPLAN: Monitor CV, resp status, frequent aggressive pulmonary toileting, pain management.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-12 00:00:00.000", "description": "Report", "row_id": 1531435, "text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: OPENNING EYES SPONTANEOUS. INCONSISTENTLY FOLLOWS COMMANDS. PERRLA,BRISK. MAE WITH PURPOSEFUL MOVEMENT. +GAG/COUGH. PT VERY ANXIOUS MEDICATED WITH 1MG IV ATIVAN WITH GOOD EFFECT.\n\nCARDIAC: HCT: 28.0. NSR. HR:72-86. ABP: 123-151/66-80. LOPRESSOR IV WITH GOOD EFFECT. +RADIAL,FEMORAL,POPITEAL,PT +DP X2. HEPARIN SC. CSL ON.\n\nPULM: 50% TRACH COLLAR. POX: 94-100%. RR: 24-28. LS: COARSE THROUGHOUT. SX FOR COPIOUS AMTS OF THICK WHITE SPUTUM. MDI GIVEN AS SCHEDULED. TRACH CARE DONE X2.\n\nGI: TOLERATING TF. NO RESIDUALS. ADB:SD,+BSX4,S,NT. MIDLINE INCISION HEALING WELL. R-GROIN VAC DRESSING INTACT WITH MODERATE AMT SEROUS DRAINAGE. L-GROIN STAPLES CDI. FIB WITH LG AMTS OF THICK BROWN STOOL.\n\nGU: FOLEY WITH QS AMBER COLORED URINE. LYTES WNL.\n\nENDO: FS QID. COVERAGE PER RISS. FS: 108.\n\nINTEG: GROIN AREA RED-RASH. NYSTATIN POWDER APPLIED.\n\nIV: PIV X2. SITES WNL-PATENT.\n\nID: AFEBRILE. CONTINUES ON VANCOMYCIN. E-MYCIN FOR GI MOTILITY.\n\nSOCIAL: NO FAMILY CONTACT OVERNIGHT.\n\nPLAN: MONITOR NEURO STATUS. AGGRESSIVE PULM HYGIENE. TITRATE SUPPLEMENTAL OXYGEN AS TOLERATED. WOUND CARE. SURVAILLENCE LABS PRN. INCREASE ACTIVITY AND TF AS TOLERATED. MEDICATE PRN FOR PAIN/ANXIETY. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-12 00:00:00.000", "description": "Report", "row_id": 1531436, "text": "RESPIRATORY CARE:\n\nPt remained off vent support over night. One episode of dyspnea, increased WOB- assessed for replacing vent support. Pt given antianxiety med, and settled down. Vent remains standby, will pull today if remains stable. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-13 00:00:00.000", "description": "Report", "row_id": 1531441, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nLUNG SOUNDS STILL COARSE AND PT WITH COPIOUS AMTS OF THICK WHITE SECRETIONS, OCC ABLE TO EXPECTORATE SECRETIONS.\nTF NUTREN REPLETE WITH FIBER INCREASED TO 40CC/HR, RESIDUALS INCREASED TO 110CC AT 1600, ABD NOTED TO BE FIRMLY DISTENDED AND RESIDUAL WITH BILIOUS CONTENT THEREFORE TF STOPPED, DR. AWARE.\nCONT TO MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. PT CONSULT PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-14 00:00:00.000", "description": "Report", "row_id": 1531442, "text": "Respiratory Care:\n Patient continues on 40% trach collar with SpO2>97%. BS diminished aeration. He received albuterol and atrovent Q4, tobra , and flovent MDI . He continues to be suctioned for sticky, yellowish secretions. He is awake and attempts to communicate. He may benefit from a Passy Muir Valve. Plan to continue with pulmonary hygiene and nebs.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-23 00:00:00.000", "description": "Report", "row_id": 1531360, "text": "focus hemodynmics\ndata: neuro: awake and very uncooperative. refusing all treatment despite full explanation. attempting to remove lines. pulling o2s prongs offf. moves all extremites on the bed. sitting up in tthe bed and become frustrated with all the lines connected to him. asking for beer. becomes agitated easily. ativan 0.25mg iv given x1. seen by dr for agiatation.\n\nresp: breath sounds very course. refusing chest pt. becomes agiatated. o2sats 88-93%. ccoughs but unable to raise any sputum. chest pt refused by the pt. later pt agreed to chest pt but unable to raise sputum. abg 7.42-47-52-32 on 6 liters o2. open face mask added and still unable to raise sputum. repeat abg 7.4042-76-27 albuterol rx given by the resp therapist. wbc 19.4\n\ncardiac: remains in nsr. heart rate 80-90's. bp 140-180's. lopressor 10mg iv given as ordered.hct 24.7, k 4.1 magnesium 2.1.\n\ngI abd distended and soft to touch. no stool. ngt draining brown liquid drainage. npo. although mouth care attempted pt refuses and wishes to have large cup of h2o. dr in to see pt and informed pt no h20 at this time.\n\ngu: foley patent and draining amber colored urine.\n\naction: chest pt attempted and pt only allowed x1. becoming agitated. ativan 0.25mg iv given. lopressor 10mg iv given as ordered. o2 at 6liters via np. albuterol neb treatment given. breath sounds course. wbc elevated 19.4. mso4 2mg iv x1 given. with fair results. abd incision clearn and intact. scrotal area swollen and elevated on a pillow. seen by the vascular team this am.\n\nresponse monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-14 00:00:00.000", "description": "Report", "row_id": 1531443, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt remains alert. UTA orientations trach. Pt mouthing words at times. Pt is non compliant with care at times becoming agitated with turning and bathing ativan prn as indicated for agitation.\nCV: HR-SR with occ PVC's. Lopressor Q4hrs cont. Lytes okay. SBP 110's to 160's hydralazine X1 for hypertension. Afebrile. Vac drsg to groin. + PP/PT.\nResp: Remains on trach mask. SXN for moderate amts of yellow/white thick sputum. Pt with strong productive cough as well. Nebs given via RT. Lungs clear to coarse throughout.\nGI/GU: TF remain off abd distention and high residuals on day shift. ? re-eval today. Belly is no soft but remains distended + BS sm amts of stool. FIB . Foley patent drng amber urine.\nID: REMains on abx therapy\nEndo: RISS required no coverage over night.\nPlan: cont to monitor resp status. ? switch IV lopressor to PO. ? CT scan. ? re-eval TF.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-14 00:00:00.000", "description": "Report", "row_id": 1531444, "text": "Frequently suctioned for copious amount of clear sputum.OOB/Chair today.Treated earlier today with neb then successive RT therapy done with MDI ambu to patient.CXR (R) base opacity,(L) lobe atelectasis,BS coarse. On Tobramycin,Flovent,alb/atrovent Q4.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-23 00:00:00.000", "description": "Report", "row_id": 1531361, "text": "Resp Care\nPt given PRN Albuterol tx X 2 to increase airway clearance and coughing. ABG showing hypoxia and Spo2 on 6 L NC =93%. Plan to continue neb treatments and moniter oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-23 00:00:00.000", "description": "Report", "row_id": 1531362, "text": "Resp Care\nBS coarse bilaterally and throughout. No change in BS post neb treatments.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-23 00:00:00.000", "description": "Report", "row_id": 1531363, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, AGITATED AND AT TIMES, YELLING OUT, USING INAPPROPRIATE LANGUAGE TO STAFF. DIFFICULT TO ASSESS ORIENTATION DUE TO PT'S UNWILLINGNESS TO ANSWER QUESTIONS. ATIVAN GIVEN Q 4HOURS WITH FAIR EFFECT. MAE. OOB TO CHAIR WITH ASSIST.\nCV- BP STABLE WITH LOPRESSOR GIVEN AROUND THE CLOCK, AVERAGING 120-150'S, 170'S WHEN AGITATED. HR 80'S, NSR WITH OCCASIONAL PVCS, LYTES CHECKED AND REPLETED AS NEEDED. SURGICAL INCISIONS CLEAN AND DRY, OTA. PLATELETS 50 THIS AFTERNOON, WILL CONTINUE TO MONITOR. SWAN DC'D, CVP 4-6\nRESP- LUNGS COARSE, OCCASIONAL WHEEZES. ALBUTEROL NEBS GIVEN WITH GOOD EFFECT. FREQUENT CHEST PT, HOWEVER DIFFICULT DUE TO PT BECOMING , REFUSING CARE, THRASHING IN BED. EXPLAINED TO PT THE IMPORTANCE OF CHEST PT AND IS, HOWEVER PT REFUSING TO COOPERATE. COUGH WEAK, ABLE TO OCCASIONALLY RAISE THICK TANNISH SPUTUM. O2 SAT RANGING FROM 87-93%. ABGS DRAWN THROUGHOUT THE DAY AND DR. NOTIFIED WITH RESULTS, PCO2 REMAINING 60. PT APPEARING TO BE IN DISTRESS AT TIMES, RESP RATE INCREASING, BECOMING LESS ABLE TO RAISE SPUTUM BY COUGHING. ? NEED FOR NT SUCTIONING IF PT CAN TOLERATE.\nGI/GU- ABD SOFT, HYPO BS. NG TUBE REMAINS OUT, NO NAUSEA OR VOMITING. UOP MINIMAL, LASIX GIVEN X 2 WITH RESULTS, PT NEGATIVE FOR THE DAY.\nID- LOW GRADE TEMP.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-25 00:00:00.000", "description": "Report", "row_id": 1531368, "text": "condition update\nneuro: opens eyes to voice, able to state name only - otherwise incomprensible sounds. Agited frequently through the night with any stimulation - attempting to pull at foley and continously removing face mask. Soft limb restraints in place. Dr. at bedside to evaluate. Haldol given with mild effect, then d/c'd d/t prolonged qt interval (.49). Valium d/c'd.\ncv; nsr 70's-90's with occasional pvc's. lopressor continues q4 hrs., sbp remains below 140. Peripheral pulses remain unchanged. K+ (3.6) repleted this am. LR continues at 75cc/hr. abd and bilat. groin incisions intact - right groin draining mod. amts. serous drainage.\nresp: ls coarse bilat., 02 sat 96-99% on .95% high flow fact tent. NTS for large amts. thick yellow sputum. alb/atrov nebs atc per r.t.\nchest p.t. done as tolerated.\ngi: abd soft distended, +bs, small loose bm overnight. npo.\ngu: foleying draining marginal amts. urine with sediment. Dr. aware of urine appearance.\nendo: no ssri coverage necessary\nskin: intact\nID: afebrile, vanco zosyn continue.\nplan: monitor neuro status - safety, pulmonary toileting, monitor u/o, ? dobhoff placement today.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-25 00:00:00.000", "description": "Report", "row_id": 1531369, "text": "Resp Care\nPt continues high flow mask set at 80%. Nebs given as ordered. BS coarse bilaterally, NT suctioned for moderate amounts of thick yellow secretions. Spo2=94-98%. See CareVue for details and specifics. Continue to treat with nebs as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-25 00:00:00.000", "description": "Report", "row_id": 1531370, "text": "Resp Care\n\nPt remains on 80% hi-flow mask with spo2 in the mid 90's. Receiving scheduled bronchodiltors. Required 2 NTS for thick yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2152-01-25 00:00:00.000", "description": "Report", "row_id": 1531371, "text": "FOCUS; STATUS UPDATE\nDATA;\nPT CONTINUES TO BE AGITATED MOST OF THE TIME, BUT OVERALL SLIGHTLY MORE CALM THAN YESTERDAY. NO HALDOL OR VALIUM GIVEN TODAY. FAMILY IN TO VISIT AND ENCOURAGED TO SPEND TIME WITH HIM AND REFOCUS HIS ATTENTION TO THE FAMILIAR WITH GOOD RESULTS. HE FOLLOWS COMMANDS AND IS MORE COOPERATIVE WHEN ASKED TO OPEN HIS EYES WHEN PROVIDING CARE. SPEAKING MORE TODAY WITH LESS OFFENSIVE LANGUAGE, LESS AGGRESSIVE AND COMBATIVE.\n\nLUNGS BILATERALLY COARSE AND AT TIMES WHEEZY. NEBS GIVEN BY RESPIRATORY THERAPY WITH GOOD RESULTS. HE CONTINUES TO RAPIDLY DESAT TO THE LOW 80'S WHEN HE REMOVES HIS O2 SOURCE HOWEVER AND SO CONTINUES TO NEED SOFT LIMB RESTRAINTS AS WELL AS CAREFUL SUPERVISION.\n\nABD SOFT WITH MULTIPLE SOFT BOWEL MOVEMENTS TODAY. GUAIAC NEG.\n\nRIGHT FEMORAL SITE SUTURES INTACT WITH MODERATE AMOUNTS OF SEROUS DRAINAGE REQUIRING MULTIPLE DSD CHANGES. L FEMORAL SITE WITH STAPLES INTACT AND NO DRAINAGE. POSITIVE L DOPPLER PEDAL PULSES, ABSENT ON RIGHT.\n\nPLAN;\nCONTINUE TO CAREFULLY MONITOR RESPIRATORY STATUS AND PROVIDE POSITIVE REINFORCEMENT. ENCOURAGE FAMILY TO VISIT. F/U ON NUTRITIONAL NEEDS AS HE IS UNABLE TO TAKE PO'S D/T MENTAL STATUS AND RISK FOR ASPIRATION.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-26 00:00:00.000", "description": "Report", "row_id": 1531372, "text": "Respiratory Care Note:\n\nPt remain on Cool mist, high flow ~80% Fio2. We sxtn by NTS thru right nare for thick tan secretions. Nebs adm as ordered with BS are low piotch wheezes, No changes. Plan: pul toilet & Continue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-28 00:00:00.000", "description": "Report", "row_id": 1531379, "text": "vss. pt mumbling incoherent words. not focusing on person. yelling out during cpt/bathing. ^b/p and ^rr and moaning ? in pain-morphine 2mg iv x2 given w/ b/p and rr down. pt somewhat calmer then previously reported. cs-scat.rhonchi. cnr'ing putting yankanuer back of throath\nfor thick yell sputum. very congested weak cough.o2sats 94-96 on hiflow cfm 90%.\nurine output 60-100cc/hr amber color.\nabd. soft. abd. inc c&d ota. rt groin w/ staples draining mod. serous\nfliud.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-28 00:00:00.000", "description": "Report", "row_id": 1531380, "text": "Respiratory Therapy\nPt remains on .95 Hi flow FM for sats in low to mid 90's. BS coarse rhonchi bilaterally. Deep oropharyngeax sx for thich yellow tan secretions. Weak gag reflex.. Plan: continue to monitor resp status. Continue pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-28 00:00:00.000", "description": "Report", "row_id": 1531381, "text": "NPN 7am-7pm\n\n68 yr old male s/p aorta-bifem & mesenteric bypass graft with re-implantation on .\n\nROS: See carevue for exact data\n\nN: Poor neuro exam, pt very lethargic, arouses with painful stimulus. Will open eyes to name at times otherwise is unable to identify self. Pt moans/yells, incomprehensible sounds. Does not follow commands, no eye contact. ICU team aware of neurological status, will monitor over next few days to see if pt arousing more. Mae's, purposeful, localizing pain. No pain medicine given today, when pt not aroused appears very comfortable. Morphine available as needed.\n\nCV: HR 60-80's, SR occasional PVC. Lopressor ATC 10 mg tolerates well. SBP 130-150 hyperdynamic to 180 with agitation. Pt with venodynnes on, weakly palpable pulses, confirmed with doppler. Ext's cool to touch but normal in color. Cap refill slightly impaired, ICU team aware. Pt on DVT prophylaxis. IVF at KVO rate. Pt with right IJ central line, drsg today.\n\nResp: LS coarse, aggressive CPT/NTS. Suctioned for moderate amts of thick tan secretions. Impaired gag. Pt on high flow O2, when off oxygen will desat to 80's with slightly slow recovery, otherwise O@ saturation 93-100%. RR 20-29.\n\nGI: Abd soft, pos BS. No bm today. Will neeed speech and swallow eval and lg increase in neuro status before PO feeds. TPN currently for NPO status at 62.5/hr.\n\nGu: U/o adeq amts, amber in color.\n\nSkin: Abd incision with staples intact, no drainage. Bilat groins OTA with staples. Lg amt of serous fluid emptying from right groin. 1 pad every few hours. Plan to place wound vac drain per primary team. Team aware supplies available at bedside. Otherwise skin intact.\n\nEndo: Bld sugars 130-160 coverage per ss.\n\nLytes: Wnl, Na 147 has been running > than nml limits.\n\nID: Afebrile. Pt cont on vanco/zosyn for general coverage.\n\nP: Cont to monitor neurological status. Medicate for pain as needed. Monitor resp status, aggressive CPT/pulm toilet. Cont TPN, will need to re-assess nutritional status. Speech and swallow. Provide emotional support. Cont with bilat soft wrist restraints due to pt pulling at tubes and drains. Monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-29 00:00:00.000", "description": "Report", "row_id": 1531382, "text": "Respiratory Therapy\nPt remains on 95 high flow for sats 96-99%. Attempted alb/atrovent neb at midnight did not tolerate sats 87%. Pt vocalizing loudly most of night.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-29 00:00:00.000", "description": "Report", "row_id": 1531383, "text": "Focus-Condition Update\nData-Pt opens eyes at times, occas moaning out loud. Pt moves all extremities, does not follow commands. WBC up to 21 today, pt afebrile. O2 on 95% high flow mask. Breath sounds coarse with occas wheezes. Pt nasal suctioned x2 for thick sm amts yellow secretions.\no2 sats 98-100%. Abd soft/distended with hypoactive bowel sounds, incont sm amt stool. BUn elevated. VAC dressing intact to R groin incision.\nAction-O2 mask weaned down to .80%. Neb treatment x1 given.\nAbd CT scan done this pm. Pt hydrated prior to scan with RL 500ccx1 then maintenance IV at 100cc/hr.\nResponse-Pt more awake. Tolerating weaning of O2. CT scan results pending\nPlan-Continue to monitor closely. Wean O2 as tol.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-30 00:00:00.000", "description": "Report", "row_id": 1531384, "text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nAfebrile. Neuro unchanged; yelling and moaning off and on, but otherwise not communicating, occasional eye contact and swearing only. Dozing off inbetween yelling and appears comfortable. States \"get out of here\" when turned and chest pt performed. Lungs coarse, sats 96-98 on 80% fio2 when calm. Often attempts to remove o2 mask and quickly to 60s. HR NSR, lopressor given per order. BP wnl. UO adequate. Hep gtt started for CTA results showing a clot near the mesenteric and graft site. ?Small bowel obstruction with possibility of a small bowel resection? Guiac +, mucousy stool. Abdomen firmly distended. Difficulty hearing bowel sounds d/t pt yells out while listening. Dopp pulses on right. palpable left. Emotional support provided and frequent encouraging for cough and deep breathing with NO effect. Pt only yells and moans. Plan: hep gtt with ptt monitoring goal 30-50. Evaluation of need for surgery. Monitoring of graft sites and incisions to groin, right with vac dressing over. Please refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-30 00:00:00.000", "description": "Report", "row_id": 1531385, "text": "Nursing Addendum to Note 7p-7a\nCorrection: PTT goal on heparin gtt is 50-70.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-31 00:00:00.000", "description": "Report", "row_id": 1531391, "text": "condition update\nplease see carevue for all specifics;\nneuro: sedated on 2mg/hr of midaz, arouses to noxious stimuli, does not follow commands, mae spontaneously, pupils equal and reactive (left slightly sluggish at times).\ncv: nsr 70-80's with rare pvc/pac. bp dips to high 80's/90's intermittently, self resolves. Pt received 500cc NS bolus for cvp 6-8 per Dr. . Heparin gtt continues at 1100units/hr, ptt theraputic at 57.5 this afternoon (goal 50-70). Peripheral pulses are dopplerable. Hct stable at 29.1.\nresp: no vent changes made this shift, ls clear/diminished, suctioned for mod. amts. thick yellow sputum. abg's acceptable.\ngu: foley draining adequate amts. clear amber urine.\ngi: abd soft distended, +bs, small liquid bm, guiac pos. - dr. and sicu ho notified. Dobhoff placed at bedside by sicu ho, placement verified by chest x-ray, trophic tube feeds initiated at 10cc/hr. TPN continues\nendo: no ssri coverage necessary\nID: abx discontinued as discussed on rounds with dr. .\nplan: check ptt q 6hrs - titrate heparin gtt to goal ptt 50-70, pulmonary toileting, monitor abg's, continue trophic tube feeds, monitor hct.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-01 00:00:00.000", "description": "Report", "row_id": 1531392, "text": "1900-0700 NPN\nSee careview for specifics:\n\nNeuro: opens eyes to painful stimuli. Pupils equal and reactive. Withdraws all extremities to nail bed pressure, does localize with BUE. Not following commands.\n\nPain: Dilaudid po 2mg prn for pain, pt with grimice and increase in blood pressure with pain/discomfort.\n\nC/V: Afebrile. SR with occasional PVC's, HR 70-80's. SPB 100-120's up to 130's with discomfort/stimulation, down to 90's if medicated/calm. CVP 4-9. Positive pulses to . Heparin gtts @ 2200units/hr. PTT within goal (50-70)\n\nResp: Cont on CPAP . SXN for mod amt thick white secreations. RR 22-30, no distress noted.\n\nGI/GU: Replete with fiber full at 10cc/hr (goal) tolerating well. Abd softly distended. No BM this shift. Cont on TPN. Foley with adequate urine output.\n\nSkin: Midline abd incision CDI with no drainage. Right fem site with VAC dsg, intact. Left fem site with DSD CDI. No breakdown noted.\n\nPlan: Cont on heparin gtts. Continue on tube feeds as tolerated and TPN until tube feed rate is increased. Wean ventilator as tolerated. Monitor hemodynamics, pain managment, provide emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-02 00:00:00.000", "description": "Report", "row_id": 1531399, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 10/+8 tol well with stable ventilation/oxygenation on present vent settings. BS clear to course sxing for small amts of thin white secretions. ETT resecured at 23cm at the lip. MDIs given x3 with little effect noted. Pt weaned to PSV 5/5 with attempt to extubate however pt became extremely agitated with ABG drawn at the time revealing resp acidosis and mild hypoxemia thus requiring increase PS level and sedation. Will cont with vent support and reassess tomorrow AM for possible extubation.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-02 00:00:00.000", "description": "Report", "row_id": 1531400, "text": "condition update\nneuro: precedex gtt off at 1200, by 2pm pt alert, tracking in room, attempting to mouth words and intermittently following simple commands. Shortly thereafter, pt became very agitated, thrashing in bed, attempting to pull out e.t. tube, dr. notified, 1mg ativan and 50 fentynal given with good effect. Currently pt is adequately sedated with prn boluses of fentynal/ativan.\ncv: nsr with rare pvc, sbp stable. peripheral pulse dopplerable, palpable. Ptt within goal of 50-70 on 1100 units heparin gtt. hct stable. 20mg lasix given with adequate diuresis, goal is 1-1.5 liters negative today.\nresp: Vent. weaned to with goal to extubate, abg not acceptable to extubate per dr. , pt placed on cpap . Will do rsbi/sbt in am. ls coarse, suctioned for small amts. thick white sputum.\ngi: abd soft distended, bs absent. TF restarted this afternoon, per Dr. . no bm this shift.\ngu: foley draining adequate amts. clear yellow urine.\nendo: no ssri coverage necessary\nplan: monitor tube feed residuals, hold for >100cc, fentynal/ativan prn agitation, pulmonary toileting, rsbi/sbt in am, ? extubate in am, monitor ptt, goal 50-70.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-03 00:00:00.000", "description": "Report", "row_id": 1531401, "text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: OPENS EYES SPNTANEOUSLY. INCOSISTENTLY FOLLOWS COMMMANDS. PERRLA,BRISK. MAE WITH PURPOEFUL/NON-PURPOSEFUL MOVEMENT. +GAG/COUGH. PT VERY . MEDICATED WITH ATIVAN AND FENTANYL WITH GOOD EFFECT.\n\nCARDIAC: HCT: STABLE. NSR. HR: 67-94. SBP: 124-158/47-66. HEPARIN GTT AT 1100 UNITS PER HR. GOAL PTT: 50-70. +RADIAL,FEMMORAL.POPITEAL,PT AND DP X2. +CSM ALL EXTREMITIES. CLS ON.\n\nPULM: INTUBATED. CPAP/50%/5PS/8PEEP,RSBI 30.3. POX: 96-100%. LS: R+LUL COARSE,DIMINISHED BIBASILAR. SX FOR SM AMTS OF THICK WHITE SPUTUM. CT PT X2.\n\nGI: TPN. TOLERATING TF WITH NO RESIDUALS. ABD:SD,+BSX4,S,NT. MIDLINE INCISION APPROXIMATED AND HEALING WELL. R-GROIN VAC DRESSING INTACT WITH SEROUS DRG. L-GROIN STAPLES CDI. LG BM X1.\n\nGU: FOLEY WITH QS URINE. K-3.9, REPLETED WITH 20MEQ KCL. LASIX GIVEN X1 WITH GOOD DIURESIS.\n\nENDO: FS QID. COVERAGE PER RISS.\n\nIVL: R-CVL +R A-LINE SITES WNL AND DRESSINGS CDI.\n\nID: T-MAX: 98.1. CONTINUES ON ZOSYN AND VANCOMYCIN. AM VANCOMYCIN TROUGH TO BE SENT.\n\nSOCIAL: DAUGHTER CALLED. CONDITION UPDATE GIVEN.\n\nPLAN: Q 4 HOUR NEURO CHECKS. MONITOR HEMODYNAMICS. HEPARIN GTT GOAL PTT BETWEEN 50-70. CONTINUE DIURESIS-MONITOR LYTES. PULM HYGIENE. TITRATE VENT SUPPORT AS TOLERATED. AM SBT. SURVAILLANCE LABS PRN. MEDICATE PRN FOR PAIN/AGITATION. REPOSITION Q2. ADVANCE TF AS TOLERATED. PROVIDE EMTOIONAL SUPPORT TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-05 00:00:00.000", "description": "Report", "row_id": 1531410, "text": "Nursing Progress Note\n\nSee Carevue for specifics\n\nNeuro: Opens eyes to stimuli. Purposeful movements in all ext's. localizes painful stimuli. PERRL. Ativan 1 mg prn administered for agitation/anxiety with good effect.\n\nCV: NSR. No ectopy. HR 80's. Lopressor po held. Neo gtt off. SBP 100-110 now 130's. Compression sleeves on. Heparin gtt at 1150 units/hr. for PTT 79. Goal PTT 50-70. TMax 100.1 Ax.\n\nResp: Intub, vented currently on CPAP 5 and 15. ABG's WNL. LS clear to coarse in apices, diminished at bases. Suctioned frequently for copious amounts thick yellow sputum. Inhalers administered as ordered. Chest PT done.\n\nGI: Abdomen soft, distended. +BS. TPN at 62.5. TF's still on hold. NGT to CLWS draining bilious output-250 cc's this shift. Reglan added to medication regimen. FIB in place draining liquid brown stool-C.Diff culture sent.\n\nEndo: FBS well-controlled with RISS.\n\nSkin: Midline abdominal incision approximated, OTA. Right femoral site with sutures leaking large amounts serous fluid-covered with gauze sponges and DSD-changed prn. Left femoral site with staples C/D/I no drainage. Large red, yeast-like rash over perineum-Nystatin cream applied.\n\nLabs: Increased WBC-blood, sputum and urine cultures sent. CBC with diff sent. CXR much improved. Flagyl added to antibiotic regimen. KUB done. CT cancelled. LFT's trending down. Lactate 0.9. K 3.6 repleted with 20 meq.\n\nplan: Family meeting today-consent obtained for tracheostomy. continue monitor VS, resp status, provide aggressive pulm toilet, monitor hemodynamics maintain goal SBP>90 MAP >60, NGT drainage, skin, labs.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-06 00:00:00.000", "description": "Report", "row_id": 1531411, "text": "Resp: Rec;d pt on psv 15/10/50%. Ett #8 retaped and secured @ 23 lip. BS are coarse bilaterally. Suctioned for small to moderate amounts of thick yellow to tannish secretions. MDI administere as ordered alb/atr with no adverse reactions. Pt had episode of tachycardia around midnight, lopressor administred pt back into sinus. Peep decreased to 8. AM ABG 7.40/45/99/29. RSBI=76. Willl continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-07 00:00:00.000", "description": "Report", "row_id": 1531417, "text": "REspiratory Care:Pt remains orally intubated and vented. Pt placed on today, pt passed. After pt placed on PS, Vt between 500-600, RR 16-25, SpO2>95%. Lung sounds coarse that clear with suctioning. Suctioned for thick white secretions. MDIs given as ordered. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-07 00:00:00.000", "description": "Report", "row_id": 1531418, "text": "Update\nSee Carevue for specifics\n\nTmax: 100.2.\n\nNeuro: Unable to fully assess d/t ETT. Will open eyes to voice or on own, does not follow commands, shakes head vigorously when asked to do something. All extremeties exhibit normal strength/lift & hold. PERRL. Becomes extremely agitated if stimulated.\n\nCV: NSR with rare PVCs. SBP can be labile, ranging from 90-120. Team is aware. A-line sharp, dsg changed. Type & cross match sent.\n\nResp: LS very coarse. Sxn'd frequently for thick white secretions. Chest PT done. No vent changes.\n\nGI: NGT to LCS & putting out bilious fluid. Abd soft, hypoactive BS. No stool this shift. .\n\nSkin: Abd incision approximated/healing. Open to air. L groin sutures CD & approximated, open to air. R grown sutures draining large amounts serous fluid. Drainage bag replaced by wound vac per vascular surgery.\n\nID: Vanc trough 15.2 this a.m. VRE & MRSA cxs sent.\n\nSocial: Daughter called, said she'd come in to visit at 13:00 but did not show up.\n\nPlan: Trache tomorrow. Monitor VS overnoc. Tx for agitation.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-07 00:00:00.000", "description": "Report", "row_id": 1531419, "text": "Addendum\nHeparin gtt d/c'd.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-08 00:00:00.000", "description": "Report", "row_id": 1531420, "text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt with low grade temps. No neuro changes. Ativan prn q2 hours for agitation, fentanyl for bath. HTN and tachy with bath, settling out afterwards with fent. Freq suctioning for thick white secretions via ETT. Coarse lung sounds throughout. ABG good. Bowel sounds hypoactive abdomen softly distended. NGT with lg amt bilious out. HR nsr 80s when calm up to 113 with agitation. sbp 120-130s when calm up to 190 with agititation. UO adequate drk amber/ sometimes blood-tinged and md aware, at times turning clear yellow. Plan: cont to medicate for agitation and pain. Trach and peg sometime today. Cont to monitor urine and treat yeast on groin, buttocks. Please refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-08 00:00:00.000", "description": "Report", "row_id": 1531421, "text": "Resp: Pt remains intubated ett#8, 23 @ lip. PSV 15/+/50%. Bs are coarse bilaterally and suctioning copious amounts of thick white secreitons. MDI's administered as ordered alb/atr with no adverse reactions. AM ABG 7.34/42/160/24. RSBI=66. Plan to trach and peg today.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-08 00:00:00.000", "description": "Report", "row_id": 1531422, "text": "Respiratory Therapy\n\nPt trached in OR this shift w/ #8.0 Portex trach. On A/C for brief period after return to SICU, weaned back to +15PSV/+5PEEP Vt ~500 RR ~20 maintaining Ve ~10L/M. SpO2 90s. BS diminished t/o, suctioned for small amounts of thick white sputum. MDIs given as ordered. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; continue to wean PSV as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-10 00:00:00.000", "description": "Report", "row_id": 1531429, "text": "NPN\nPlease see CareVue for full assessments.\nNEURO: to stimuli, sometimes to voice. Inconsistent w/following commands but attempting to communicate by mouthing words and nodding. Less agitated. Ativan PRN x2 w/effect. Fentanyl for comfort-Abdominal pain. Pt. wincing when LUQ palpated.\n\nCV: SR w/rare PVC's. HR 70's-80's. x1 brief episode tachy to 110's self resolved.SBP stable 130-150's. Lopressor IV per schedule. Hydralx1 for SBP 170's w/BP returning to 120's. BiCarb IVF post CT completed. Per primary team MD seen. Increased fluid collection at graft site(S/P aorto bifem BPG). ?plan of action. Vac @right groin reinforced/intact. Draining small amt serous fluid. Scant amt serous fluid noted from left groin incision with repositioning. Staples OTA. Hct stable. WBC15.9. K3.6repleted. PPP.\n\nRESP: #8 Trach from . CPAP+PS. No changes made to vent overnoc. ABG's WNL. MDI's by RT. LS rhonchi-coarse R>L. RR20's. Tachypneic to 30's w/stimulation. Sxn for small amts tan thick secretions. Lt yellow gelatinous secretions noted from trach site. Trach care performed -pt uncooperative.\n\nGI: NPO on TPNw/lipids. Abd softly distended. Tender to palpate LUQ. Pt. winces to touch. PEG to gravity. Drained 1450cc this shift. Bilious drainage noted to have flecks of blood. MD notified on rounds.\nNo stool this shift. +flatus.\n\nGU: Foley replaced . UCx sent-pending.\nINTEG: Peri area cont. w/red rash. Nystatin cream applied.\nPLAN: Monitor neuro status, CV, aggressive pulm. toileting, ?trach collar this AM, monitor PEG output, ?initiate TF, maintain vac dressing, reposition to maintain skin integrity.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-10 00:00:00.000", "description": "Report", "row_id": 1531430, "text": "Respiratory Care Note\nPt received on PSV 10/5 and placed on trach mask trial. ABG on trach mask within normal limits. BS coarse bilaterally with expiratory wheezes. Pt suctioned for moderate to copious amts thick secretions. MDI's given with improved aeration. Plan to continue on trach mask trial as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-10 00:00:00.000", "description": "Report", "row_id": 1531431, "text": "Please See Carevue for Specifics.\n\nAlert, nodding and mouthing words, orientation is unknown. Denies pain, MAE, does not follow commands. NSR, CVP is dampened. SBP 130-150, 10mg IV hydralize adm once with effect. 5mg IV lopressor every four hour adm ATC. Trach collar with adequate ABG's. Lungs are coarse with occasional wheezes. Suctione frequently throughout the day for copious amounts of yellow/whitich secretions. Abd is soft-firmly distended with BSX4. Incontinent of three small loose BM today, FIB placed. Gtube clamped and checking residuals every hour hours. Foley with sediment amber urine. Right groin wound VAC intact with scant amounts of whitish drainage. Left groin staples are CDI. Buttocks and scrotal area are pink and dry. Miconazole powder applied. to affected areas. Daughter called this afternoon and is having car problems and will not be able to travel to to visit.\n\nPOC: SW and CM following pt. Continue to assess pain, monitor hemodynamics, and encourage to CDB. Monitor skin integrity, continue to offer emotional support to pt and pt family. Discharge to rehab when pt ready ?.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-11 00:00:00.000", "description": "Report", "row_id": 1531432, "text": "Resp Care\nPt placed on vent after pt desated and had resp distress. pt suctioned mod amt of thick white secretions. Mdis given. Rsbi 53. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-12 00:00:00.000", "description": "Report", "row_id": 1531437, "text": "FOCUS; STATUS UPDATE\nDATA;\nSEE CAREVUE FLOWSHEET FOR FULL DETAILS.\n\nPT ALERT BUT NOT FOLLOWING COMMANDS FOR STAFF UNTIL FAMILY CAME IN TO VISIT. HE NOW FOLLOWS ALL COMMANDS AND HAS ATTEMPTED TO COMMUNICATE BY MOUTHING WORDS AND WRITING ON A BOARD. DIRECT EYE CONTACT WITH SPEAKER AS WELL. PERL AT 2MM. MOVING ALL EXTREMITIES IN BED. CALMER TODAY WITHOUT ANY SEDATION.\n\nLUNGS BILATERALLY COARSE WITH SOME EXPIRATORY WHEEZING AT TIMES. INHALERS PER RESPIRATORY THERAPY AS ORDERED WITH GOOD EFFECT. SUCTIONED FOR COPIOUS AMOUNTS OF THICK YELLOW SECRETIONS FREQUENTLY.MAINTAINING SATS 98-100%, NOW ON 40%O2 VIA TRACH COLLAR.\n\nTUBE FEEDS RESTARTED THIS AM AFTER HOLDING FOR HIGH RESIDUALS. TOLERATING WELL WITH MINIMAL RESIDUALS AFTER 6HRS. ABDOMEN SOFTLY DISTENDED WITH POSITIVE BOWEL SOUNDS. NO STOOL. MAINTENANCE IV FLUIDS STARTED FOR HYDRATION.\n\nR GROIN VAC DRESSING INTACT. DRESSING CHANGED BY PRIMARY TEAM YESTERDAY AND MACCERATED SKIN NOTED ON PERIPHERY OF WOUND BY GROIN. WHITE VAC FOAM ORDERED AND PLACED BEDSIDE FOR BETTER SKIN PROTECTION. SEROUS DRAINAGE NOTED PER TEAM WITH DRESSING CHANGED. SLOWER DRAINAGE NOTED TODAY.\n\nPLAN:\nCONTINUE TO MONITOR RESPIRATORY STATUS AND SUCTION AS NEEDED. ENCOURAGE PATIENT TO INTERACT WITH SPEAKER.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-02-12 00:00:00.000", "description": "Report", "row_id": 1531438, "text": "resp care - Pt trached and on .50 TM. Pt remained stable through shift. Vent pulled. Pt able to cough and partially clear airway. Suctioning helps stengthen cough. Pt has moderate to copious amounts of thick white secretions and requires Q2 suctioning. Meds given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-13 00:00:00.000", "description": "Report", "row_id": 1531439, "text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: ALERT-OPENNING EYES SPONTANEOUSLY. INCONSISTENTLY FOLLOWING COMMANDS. PERRLA,BRISK. MAE. +GAG/COUGH. PT VERY AGITATED X2. MEDICATED WITH ATIVAN WITH GOOD EFFECT.\n\nCARDIAC: HCT: 26.3. NSR. HR: 71-91. ABP: 115-156/55-65. LOPRESSOR IV GOOD EFFECT. +RADIAL,FEMORAL,POPITEAL.PT +DP X2. CSL ON. HEPARIN SC.\n\nPULM: TRACHED ON 40% TRACH MASK. POX: 96-99%. RR: 17-28. ABG WITH GOOD OXYGENATION. LS: COARSE THROUGHOUT. SX FOR COPIOUS AMTS OF THICK WHITE SPUTUM. MDI'S GIVEN AS SCHEDULE.\n\nGI: TOLEATING TF VIA PEG,SITE WNL. NO RESIDUALS. ABD: SD,+BSX4,S,NT. MIDLINE INCISION WELL HEALED. R-GROIN VAC DRESSING CDI WITH MODERATE AMT SEROUS DRAINAGE. L-GRION STAPLES CDI. FIB SM AMT OF LIQUID BROWN STOOL.\n\nGU: FOLEY WITH QS AMBER URINE.\n\nENDO: FS QID. COVERAGE PER RISS.\n\nIVL: PIV X2 AND R-RADIAL A-LINE SITES WNL.\n\nSOCIAL: NO FAMILY CONTACT OVERNIGHT.\n\nPLAN: MONITOR NEURO STATUS. AGGRESSIVE PULM HYGIENE. TITRATE SUPPLEMENT OXYGEN AS TOLERATED. WOUND CARE. SURVAILLANCE LABS PRN. INCREASE ACTIVITY AND TF AS TOLERATED. MEDICATE PRN FOR PAIN/ANXIETY.\nPROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2152-02-13 00:00:00.000", "description": "Report", "row_id": 1531440, "text": "Respiratory Care Note:\n Patient remains off mechanical support overnight. He is on a 40% trach collar with adequate abg values. BS=bilat, coarse with scattered rhonchi. Suctioned approximately Q1 for thick, white sputum. Plan to continue monitoring, pulmonary hygiene and MDI administration Q4.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-22 00:00:00.000", "description": "Report", "row_id": 1531359, "text": "0700-1900\nSee Careview for details:\n\nNeuro: Alert and oriented x3. MAE, follows commands. At times uncooperative with care but is redirectable.\n\nPain: Abd pain at incision site controlled with morphine ivp.\n\nC/V: Afebrile. SR HR 70-80's with PVC's. Blood pressure 120-140's. PA 30's/10's. C.O. 6.28-8.46, C.I. 3.4 - 4.6.\n\nResp: Lungs coarse with rhonchi and crackles at bil bases. Congested cough but not able to clear secreations. CPT as tolerated. Cough/deep breath encouraged frequently. Using IS with encouragment but not effectivly. ABG's this am improved. No distress.\n\nGI: Abd soflty distended, bowel sounds present. NGT to LCS with small amt clear drainage. No N/V.\n\nGU: Clear yellow urine. Large amt urine output after 20 mg lasix this am. Fluid balance negative ~4liters.\n\nSkin: Midline abd incision with staples open to air, clean and dry. Bilateral femoral incisons with staples, open to air, clean and dry. No breakdown noted.\n\nSx: Wife called today and updated. Daughters into visit this afternoon.\n\nPlan: Monitor respriatory status, aggressive pulmonary toilet. Monitor pain and medicate prn. Monitor hemodynamics. Continue to provide emotional support to patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-23 00:00:00.000", "description": "Report", "row_id": 1531364, "text": "ADDENDUM:\nPT BECOMING TACHYPNEIC THIS EVENING, BP RISING, APPEARING TO HAVE RESP DISTRESS. RESIDENT CALLED AND IN TO ROOM. PT THRASHING IN BED, NOT FOLLOWING ANY COMMANDS, YELLING OUT. A-LINE DC'D DUE TO BLEEDING AT SITE, RESIDENT AWARE AND UNABLE TO FIX.\nPRIMARY TEAM PAGED AND CAME TO EVAL. NEBS GIVEN WITH GOOD EFFECT, MSO4 2 MG FOR PAIN WITH EFFECT. CONTINUE WITH SUCTIONING AS NEEDED AND SEND SPUTUM IF ABLE TO OBTAIN. CONTINUE TO MONITOR CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-24 00:00:00.000", "description": "Report", "row_id": 1531365, "text": "Resp Care\nPT placed on high flow 80%. BS coarse and wheezy bilaterally. Pt suctioned often for copious thick yellow secretions. Nebs given Q4hrs. PT getting agitated and combative when stimulated. ^ Wob, Spo2=93%. ABG showing metabolic alkalosis with PO2 in normal range.\nPlan: Continue O2 therapy and neb treatments as ordered. Continue suctioning. Moniter WOB and ABG for ? mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-24 00:00:00.000", "description": "Report", "row_id": 1531366, "text": "focus hemodynmics\ndata: neuro: confused and agitated. moves all extremities on the bed. yells out when trying to talk with him. confused to time and place. ativan iv prn. hands restrained for pt safety. mouth care given and pt becomes extremely agitated and attempting to pull at staff's fingers and arm.\n\nresp: chest pt done with extreme agitation. trumpet in place and suctioned for lg amt of thick yellow sputum. resp rate 20-39. o2sats 87-93%. abg 7.50-40-85-32. hob elevated to 45degrees. wbc 18.9\n\ncardiac: in nsr- sinu tach. inr 1.2 hct 37.4 magnesium 2.4 plts 53 lopressor 10mg iv q4hrs. k repleted. magneium repleted.\n\ngu: foley patent and draining amber colored urine. lasix 20mg ivp given with good diuresis. scrotum and penis edematous.\n\ngi abd soft with hypo bowel sounds. npo. abd incision intact. bilateral groin incision intact. no drainage.\n\naction: nasotraacheal suctioned . labs as ordered. dr obtained blood gas. lopressor 10mg ivp prn. ativan for agitation. chest pt despite agitation. update to daughter.\n\nresponse: monitor closely .\n" }, { "category": "Nursing/other", "chartdate": "2152-01-24 00:00:00.000", "description": "Report", "row_id": 1531367, "text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT VERY AGITATED, YELLING, PULLLING AT TUBES/LINES/ATTEMPTING OOB. PER DR. , IV VALIUM GIVEN X SEVERAL UNTIL PT CALM. PT CALM, BUT EASILY AGITATED. WILL ATTEMPT HALDOL IF NEEDED. OPENS EYES TO VOICE. YELLS INCOMPREHENSABLE SOUNDS. MAE, VERY STRONG. DOES NOT FOLLOW COMMANDS.\n\nCV-HR 80-110'S, ON LOPRESSOR. SBP STABLE. SKIN W+D. + PULSES ON LEFT FOOT. + PP PULSE ON RIGHT, NO DP ON RIGHT FOOT. TEAM AWARE AND REPORTEDLY UNCHANGED. INCISIONS WNL.\n\nRESP-PT TACHYPNEIC AT TIMES,ESP WHEN AGITATED. LS COARSE WITH WHEEZES AND RHONCHI. NT SXN FOR MOD AMT THICK TAN SPUTUM. SPEC SENT. STARTED ON ABX. NASAL TRUMPET IN PLACE. CPT DONE AS TOL. NEBS ATC. ON 70% FACE TENT. O2 SAT MOSTLY LOW 90'S, BUT NOW IMPROVING TO 97%. DESATED TO 56% WHEN PULLED O2 MASK OFF, BUT QUCIKLY RETURNED TO BASELINE WHEN O2 BACK ON. TEAM AWARE. WILL CON'T TO MONITOR CLOSELY. ? NEED FOR SITTER.\n\nGI-ABD SOFT, NT/ND. +BS. NPO.\n\nGU-U/O VIA FOLEY DARK AMBER AND IN LOW AMTS. TEAM AWARE. URINE LYTES SENT. IVF BOLUS X 2 GIVEN AND MAINTENANCE IVF STARTED AND U/O NOW IMPROVING. CON'T WTIH LG AMT PENILE EDEMA.\n\nENDO-SSRI.\n\nID-AFEB. ON ABX.\n\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. SAFETY. HALDOL PRN. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-26 00:00:00.000", "description": "Report", "row_id": 1531373, "text": "CONDITION UPDATE\nVSS. AFEBRILE. HYPERTENSIVE W/ AGITATION. ALERT. ORIENTED TO PERSON. MAE ON BED. LUNGS COARSE THROUGHOUT. NT SUCTIONED FOR THICK, TAN/YELLOW SPUTUM. REMAINS ON HIFLOW MASK AT 80%. ENCOURAGED TO COUGH AND DEEP BREATHE. PT QUICKLY WHEN OFF OXYGEN. ABD SOFT. SM BMX1. ABD INCISION C/D - STAPLES INTACT. BILAT GROIN INCISIONS CLEAN - STAPLES INTACT. RGROIN INCISION PUTTING OUT LG AMTS OF SEROUS DRAINAGE. PEDAL PULSES BY DOPPLER.\nCONT AGGRESSIVE PULM. TOILET. WEAN FROM O2 AS TOLERATES. CLOSE ASSESSMENT MENTAL STATUS. PT . MINIMIZE AGITATION. STRICT I/O'S. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-26 00:00:00.000", "description": "Report", "row_id": 1531374, "text": "NURSING PROGRESS PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CARE VUE FOR OBJECTIVE DAT AND TRENDS.\n\nNEURO: A+OX1. FOLLOWS COMMANDS. MUMBLES INCOHERENT WORDS. PERRLA,BRISK. MAE WITH PURPOEFUL MOVEMENT. +GAG/COUGH. PT VERY AGITATED AT TIMES-SHAKEY. MEDICATED WITH DIAZEPAM WITH GOOD EFFECT.\n\nCARDIAC: HCT: STABLE. NSR. HR: 60-80'S. SBP: 115-158/61-72. IV LOPRESSOR WITH GOOD EFFECT. +RADIAL,POPITEAL,PT + DP X2. CSL ON.\n\nPULM: 80% WITH POX: 92-98%. LS: COARSE THROUGHOUT. NT SX FOR THICK PALE YELLOW SPUTUM. ENCOURAGED TCDB.\n\nGI: NPO. TPN TO BE STARTED TONIGHT. ABD: SD,+BSX4,S,NT. NO BM.\n\nGU: FOLEY WITH QS COLORED URINE WITH SEDIMENT, SICU TEAM AWARE. BUN: 22. CREAT: 0.8.\n\nENDO: FS QID. COVERAGE PER RISS.\n\nINTEG: SKIN INTACT.\n\nIVL: R-TRIPE LUMEN SITE WNL. DRESSING CDI.\n\nACTIVITY: OOB TO CHAIR. PT ABLE TO PIVOT AND TURN WITH 2 ASSIST.\n\nSOCIAL: FAMILY IN TO VISIT. UPDATED REGARDING POC.\n\nPLAN: Q 2-4 HOUR NEURO CHECKS. MONITOR HEMODYNAMICS. AGGRESSIVE PULM HYGIENE. ENCOURAGE TCDB. MONITOR FOR SIGNS OF DT'S. MEDICATE PRN WITH DIAZEPAM/MORPHINE. SURVAILLENCE LABS PRN. REPOSTION Q2. ADVANCE DIET AND ACTIVITY AS TOLERATED. PROVIDE EMOTIONQL TO PT AND FAMILY.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-26 00:00:00.000", "description": "Report", "row_id": 1531375, "text": "BS coarse crackles, exp wheezes clearing with suction and/or nebs. Sx'd for moderate amount thick white-yellow secretions. Nasal trumpet removed, causing . FiO2 increased to 95% via high-flow system.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-27 00:00:00.000", "description": "Report", "row_id": 1531376, "text": "NURSING\n VSS, NSR, NO ECTOPY. AFEBRILE. REMAINS CALM ON IV DIAZEPAM. OCCASIONALLY WAKES AND WILL PULL AT TUBES AND LASH OUT WITH HANDS. DOES NOT FOLLOW COMMANDS. STATES NAME, NOT PLACE OR DATE. SEE CARE VUE FOR FULL SPECIFICS.\n CONTINUES ON TPN. IVF'S DECREASED TO KVO. PUTTING OUT GOOD URINE OUTPUT OVERNIGHT.\n CHEST PT AND NEBS Q 3-4/HRS. LUNGS WITH COARSE BREATH SOUNDS THROUGHOUT. COUGHING AND RAISING. REMAINS ON FM AT 95%.\n CONTINUE CHEST PT AND PULMONARY TOILET. MAINTAIN SAFETY WITH RESTRAINTS AND DIAZEPAM PRN. CONTINUE TO MONITER HEMODYNAMICS.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-27 00:00:00.000", "description": "Report", "row_id": 1531377, "text": "Respiratory Therapy\nPt presents on .95 Hi flow FM. for sats in mid 90's. pt rapidly when off mask,BS coarse rhonchi bilateral periphery W diffuse wheezesNebs as ordered W increased air movement no improvement in sats.Plan:continue pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2152-01-27 00:00:00.000", "description": "Report", "row_id": 1531378, "text": "Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: Pt has been medicated intermittently with Valium/morphine for agitation episodes. Last dose Valium at 1130 (5mg) for agitation during resp decompensation- resp improved with interventions, but pt remained agitated. Valium IV therapeutic. Versed gtt ordered by SICU team for smoother sedation course in setting of ?ETOH w/drawal. Versed initiated at 0.5mg/hr at 1200, pt became increasingly somnolent, flaccid extremities and mumbling with stimulation, unable ot participate im pulm hygiene- no resp compromise noted. Versed gtt suspended for sx of benzodiazepine overmedication vs ETOH w/drawl sx (discussed with SICU resident and , Psych CNS) Pt slept most of day, briefly agitated, agitation self-limiting and sedatives held to evaluate underlying neuro status of delirium/agitation ?hypoxia/ETOH w/drawal/ICU delirium/infection.\nPt now easily awoken, follows most commands, moving all extremities, more comprehensible words, 0 x 1 only.\n\nRESP: High flow neb mask 95% FiO2, unable to wean Fi02 today. Lungs wit hscattered crackles/exp wheeze in Left lung, right lung rhonchi and exp wheeze. Strong cough/congested/nonproductive. Unable to NT suction today. Nebs ATC, chest PT and turn/reposition q3hr. CXR today shows no acute changes. No ABG ordered today. SPO2 89-95%, RR 18-26 occassionally to 85%, responds to high-, coughing, nebs.\n\nHEMODYNAMICS: Denies CP. NSR 70-90s, Lopressor as scheduled. SBP range 110-140s. Strong pedal pulses on LLE, doppler pulses on RLE. Right femoral incision line not approx \" superior portion and draining copious amts serous fluid- Vascular team aware, no intervention. DSD changed q2hr. Abdomen softly distended, ?absent bowel sounds- no n/v.\nAdeqaute u.o. fluid balacne remains negative.\n\nID: Afbrile. Surveillance UA/urine cx collected in light of neuro status, cldy urine, results pending. Vanco/ZOsyn as ordered. Vanco level 15.6.\n\nMETABOLIC/NUTRITION: NPO due to resp status, LOC. TPN continuous. Na 148/145. Bilirubin 4.2, Dbili and Ammonia pending.\n\nSKIN INTEGRITY/COMFORT: Skin intact. Pt often pulls at foley catheter with moaning \"\", foley patent, scrotal edema noted. Oral mucosa moderately dry, 1 loose tooth as only dentia- majority of tooth exposed, no evidence of obvious infection- SICU resident aware. Mouth care given q4hr.\n\nPLAN OF CARE: Monitor resp status closely, cont pulmonary toilet measures. Monitor neuro status closely, discuss with team best sedative approach if needed acutely tonight. ?PSYCH consult tomorrow.\nTPN, monitor glucoses/electrolytes. Antiobiotics. Skin care. Emotional support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-01-30 00:00:00.000", "description": "Report", "row_id": 1531386, "text": "Respiratory Therapy\n\nPt intubated this shift w/ #8.0 OETT secured 23cm@lip for increasing PaCO2, decreased mental status; +ETCO2, +BLBS. Bronchoscopy at bedside, suctioned for small to moderate amounts of thick white sputum. Remains on PCV w/ Pinsp = 35 PEEP = 8 driving pressure = 27. Vt initially <400cc, after bronch/bronchodilator therapy Vt increased to >600cc. SpO2 90s, FiO2 weaned to .60%. See resp flowsheet for specifics.\n\nPlan: maintain support; needs head CT.\n" }, { "category": "Radiology", "chartdate": "2152-02-18 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 950080, "text": " 3:47 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ? silent aspiration\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p ABF,SMA-AO , reimplantation with trach\n REASON FOR THIS EXAMINATION:\n ? silent aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for aspiration.\n\n FINDINGS: This procedure was performed in conjunction with the Speech\n Pathology staff. Fluoroscopic guidance was provided while various\n consistencies of barium were administered. The oral and pharyngeal phase of\n swallowing were within functional limits. Barium tablet passed through the\n pharynx after several sips of liquids and moved freely through the esophagus\n into the stomach. No aspiration or penetration occurred during the exam. For\n further evaluation and recommendations please see Speech Pathology note in\n Careweb.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 949440, "text": " 9:03 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed and needs tip confirma\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with Bacteremia who needs PICC for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed and needs tip confirmation,52cm\n long,guidewire back 3cm,please at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male with bacteremia status post right-sided PICC line\n placement.\n\n FINDINGS: Comparison is made to prior radiograph dated ,\n and prior CT dated .\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH.\n\n Since most recent film, there has been interval removal of a left-sided\n central venous catheter and placement of a right-sided PICC line within the\n distal SVC. There is no evidence of pneumothorax. There is slightly\n increased left lower lobe atelectasis and worsening of the mild-to-moderate\n pulmonary edema. No evidence of new pneumonia and stable appearance to\n tracheostomy tube and G-tube.\n\n IMPRESSION:\n\n 1. Successful placement of right-sided PICC catheter with tip in distal SVC.\n\n 2. Slight increased left lower lobe atelectasis and mild-to-moderate\n pulmonary edema.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-01 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 947446, "text": " 3:08 PM\n PORTABLE ABDOMEN Clip # \n Reason: ?dobhoff placement\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with mesenteric ischemia\n REASON FOR THIS EXAMINATION:\n ?dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mesenteric ischemia with Dobbhoff placement.\n\n COMPARISON: CT, .\n\n SINGLE ABDOMINAL RADIOGRAPH: A Dobbhoff tube is seen with tip overlying the\n stomach. Scattered air is seen within the ascending colon. No evidence of\n obstruction. No free air is seen under the hemidiaphragms. Postoperative\n changes are noted including midline surgical clips, aorta-biiliac graft, and a\n long row of midline staples. Osseous structures are unremarkable.\n\n IMPRESSION: Dobbhoff tube in good position with tip overlying the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2152-01-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 947132, "text": " 5:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: mental status changes\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p ABF w reimplantation of and aorto-SMA bypass w\n PTFE\n REASON FOR THIS EXAMINATION:\n mental status changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male status post abdominal arterial vascular surgery\n approximately 1 week ago, now with mental status changes.\n\n COMPARISON: No prior study available.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Focal areas of hypodensity are noted to involve the right temporal\n and right parietooccipital cortex and subcortical white matter, consistent\n with infarction. There is local effacement of the sulci associated with the\n areas of infarction. There is no shift of normally midline structures and no\n evidence of hemorrhage. Diffuse prominence of the sulci and extra-axial CSF\n spaces indicate generalized atrophy. Chronic calcifications are noted in the\n bilateral basal ganglia. Mucosal thickening is present in the right sphenoid\n sinus air cell and ethmoid air cells. The mastoid air cells are noted to be\n hypoplastic likely congenital. No fracture is identified.\n\n IMPRESSION: Focal areas of infarction of the right temporal and right\n parietooccipital cortex and subcortical white matter. Given the relative low\n density of these areas this may be subacute rather than acute. Further\n evaluation with MR may be helpful to assess for acute diffusion abnormality.\n\n These findings were discussed with Dr. at 7 p.m. on .\n\n NOTE ADDED AT ATTENDING REVIEW: The right temporal lobe lesion shows tissue\n loss and is chronic. It may represent old infarction or an old contusion. The\n posterior temporal/parietal lesion shows only mild tissue loss and may be\n chronic or older subacute. Neither lesion is acute.\n\n Although the mastoid air cells are hypoplastic, the cells present are largely\n opacified. This may be due to acute or chronic inflammation.\n\n" }, { "category": "Radiology", "chartdate": "2152-02-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947684, "text": " 6:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please perform @ 0500 on \n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass s/p re-intubation, now s/p Dobhoff\n placement with large residual volumes, ? obstruction vs. post pyloric placement\n\n REASON FOR THIS EXAMINATION:\n Please perform @ 0500 on \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male status post aortobifemoral bypass with recent\n intubation and Dobbhoff tube placement. Assess for tube positioning.\n\n Comparison is made to prior radiograph dated .\n\n SINGLE PORTABLE SUPINE AP CHEST RADIOGRAPH\n\n A Dobbhoff tube is noted to be within the stomach, however its distal tip is\n not visualized on current radiograph and there is grossly unchanged appearance\n to satisfactorily positioned right-sided internal jugular central venous\n catheter. The tip of the endotracheal tube is approximately 5.5 cm from the\n carina. Hazy veil-like opacities involving right and left lobes are unchanged\n in appearance as is stable appearance to left lower lobe atelectasis. There\n appears to be mild improvement to previously identified interstitial pulmonary\n edema.\n\n IMPRESSION:\n\n 1. Tip of Dobbhoff tube not visualized on current radiograph. If assessment\n of distal tip is needed, we recommend abdominal radiograph.\n\n 2. Improved mild interstitial pulmonary edema.\n\n 3. Stable bilateral pleural effusions and left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947912, "text": " 11:49 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?ett placement\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man in respiratory distress s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ?ett placement\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest radiograph that is dated at 11:57.\n\n COMPARISON: , at 8:17 a.m.\n\n INDICATION: Endotracheal tube placement.\n\n Endotracheal tube terminates about 8.5 cm above the carina. Nasogastric tube\n has replaced an orogastric tube, and terminates within the stomach. Left\n subclavian vascular catheter is unchanged in position. Heart size is normal.\n Moderate right pleural effusion is again demonstrated. Bibasilar atelectasis\n is noted.\n\n IMPRESSION:\n 1. Proximal position of endotracheal tube, which could be advanced several\n centimeters for standard positioning.\n 2. Nasogastric tube terminates in stomach. Resolution of gastric distention.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947417, "text": " 1:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check for dobhoff placement\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass s/p re-intubation, now s/p Dobhoff\n placement with large residual volumes, ? obstruction vs. post pyloric placement\n\n REASON FOR THIS EXAMINATION:\n check for dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man status post Dobhoff replacement.\n\n COMPARISON: AP upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: The Dobhoff catheter terminates within\n the stomach body. The remaining lines and tubes are in unchanged position.\n The appearance of the lungs has not significantly changed since prior studies\n approximately 7 hours earlier. Moderate right pleural effusion and\n atelectasis in the middle and lower lobes are unchanged. Left perihilar\n opacification is likely unchanged, although slightly obscured by patient\n rotation. Cardiac silhouette is normal in size. No pneumothorax is\n identified.\n\n IMPRESSION: Dobbhoff tube catheter, now replaced, terminates in the stomach\n body. No significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2152-02-05 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 948028, "text": " 9:50 AM\n PORTABLE ABDOMEN Clip # \n Reason: Eval. for ileus\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with . distention and emesis\n REASON FOR THIS EXAMINATION:\n Eval. for ileus\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single AP view of the abdomen, .\n\n HISTORY: 68-year-old man with abdomen distention and emesis. Evaluate for\n ileus.\n\n FINDINGS: Comparison is made to prior radiograph from , as\n well as CT scan of the abdomen, .\n\n There is gas seen in the left colon. Aside from this, there is a generalized\n paucity of bowel gas. Part of this may be secondary to the known ascites in\n the abdomen. Overall, this is a nonspecific bowel gas pattern without\n definite evidence for bowel obstruction. However, enlarged fluid-filled loops\n of small bowel cannot be totally excluded. If there is high clinical concern,\n followup radiographs or cross-sectional imaging is recommended.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947104, "text": " 1:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass s/p re-intubation for hypercarbia and\n mental status changes\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:59 P.M. ON .\n\n HISTORY: Hypercarbia. Re-intubated.\n\n IMPRESSION: AP chest compared to :\n\n The right pleural effusion has increased. Atelectasis persists at the base of\n the right lung, and there is substantial increase in right upper lobe\n consolidation concerning for pneumonia. Interstitial edema is seen in the\n left lung. Heart size normal. ET tube in standard placement. Right jugular\n line ends close to the superior cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-29 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 947005, "text": " 5:43 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: S/P ABG, BYPASS,INCREASE WBC\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Field of view: 40 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p ABG Bypass, increased WBC\n REASON FOR THIS EXAMINATION:\n ? patent vessels\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n EXAMINATION: CTA of the abdomen and pelvis dated .\n\n COMPARISON: None.\n\n INDICATION: 68-year-old male status post ABG bypass, increased white\n blood cell, evaluate patent vessels.\n\n TECHNIQUE: Axial imaging was obtained through the abdomen and pelvis before\n and after the administration of IV contrast in the arterial and venous phases.\n In addition, coronal and sagittal reformats were performed.\n\n FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: Limited imaging of\n the lung bases demonstrates moderate-sized bilateral pleural effusions, left\n greater than right and bibasilar atelectasis. There is no evidence of\n pneumothorax or pericardial effusion.\n\n The liver is nodular in contour consistent with cirrhosis. There is a 2.1-cm\n low-density lesion in the right hepatic lobe consistent with cyst. There is\n diffuse ascites. There is pericholecystic fluid and gallbladder wall\n thickening, nonspecific given the diffuse ascites. The spleen, pancreas, and\n adrenal glands are unremarkable. Multiple bilateral low-density lesions are\n seen within the kidneys, the largest at the upper pole of the left kidney\n measuring 1.9 cm consistent with cyst. The smaller subcentimeter lesions are\n too small to characterize, however, statistically are cysts. There is patchy\n enhancement of the kidneys bilaterally which may be seen in pyelonephritis or\n infarction. The kidneys enhance symmetrically. Ascites is seen within the\n mesentery. There is no free intraperitoneal gas. There is no evidence of\n lymphadenopathy. The bowel is normal in caliber. There is suggestion of\n bowel wall thickening involving the jejunum, however, the loops are collapsed\n and this finding would be nonspecific given ascites.\n\n FINDINGS FOR CT OF THE PELVIS: There is moderate ascites. There is sigmoid\n diverticulosis without evidence of diverticulitis. There is no free\n intraperitoneal gas. There is a Foley balloon in the bladder. Gas is seen\n within the bladder presumably from catheterization. The prostate is normal in\n size. The bowel is normal in caliber.\n\n FINDINGS FOR CTA: Calcified and non-calcified plaque is seen within the lower\n thoracic aorta extending inferiorly into the abdominal aorta where there is\n (Over)\n\n 5:43 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: S/P ABG, BYPASS,INCREASE WBC\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Field of view: 40 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n opacification of the aortic lumen approximately 50% just beyond the aortic\n hiatus, this has appearance of possible previous dissection in this region\n which has now thrombosed. There is severe stenosis of the celiac axis which\n fills in distally via collaterals. There is total occlusion of the proximal\n and native SMA. The more anterior SMA graft is patent. The SMA distal to the\n graft demonstrates a 2.3-cm filling defect consistent with totally occlusive\n thrombus. There is filling of approximately 50% of the jejunal branches\n beyond this due to filling via collaterals. There is a widely patent large\n graft without evidence of thrombus. The aortic bypass is patent along\n with patent bilateral common iliacs and the bypass. There is back filling of\n the native common iliacs via collaterals from the inferior epigastric arteries\n bilaterally.\n\n IMPRESSION:\n 1. SMA and aortobifemoral bypass graft. Widely patent SMA and grafts as\n well as patent aortobifemoral graft. There is, however, a 2.3-cm long\n thrombus in the more distal SMA beyond the SMA graft with filling of\n approximately 50% of the distal branches due to collaterals.\n 2. Patchy opacification of the kidneys bilaterally which may be seen in\n pyelonephritis or infarction.\n 3. Bilateral pleural effusions and bibasilar atelectasis.\n 4. Cirrhosis and ascites.\n 5. Thickened gallbladder wall with pericholecystic fluid, nonspecific given\n the setting of ascites.\n 6. Sigmoid diverticulosis without evidence of diverticulitis. These findings\n were discussed with the SICU resident at 10:40 p.m. on .\n\n `\n\n" }, { "category": "Radiology", "chartdate": "2152-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948009, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man in respiratory distress s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 68-year-old male with respiratory distress and status post\n intubation.\n\n FINDINGS: The endotracheal tube, a left-sided central venous catheter, and\n nasogastric tube are unchanged in position. The sideport of the nasogastric\n tube is again at the gastroesophageal junction and could be advanced several\n centimeters from the optimal placement. There has been improvement of the\n right-sided pleural effusion since the previous study. No focal consolidation\n or overt pulmonary edema is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-06 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 948141, "text": " 12:33 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for ischemic appearing bowel, free air, and ta\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem, worsening leukocytosis\n\n REASON FOR THIS EXAMINATION:\n please assess for ischemic appearing bowel, free air, and tap any ascites and\n send for gram stain and culture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old man with aortobifemoral bypass, SMA bypass, and re-\n implantation, who presents with worsening leukocytosis.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with oral and IV contrast. 130 cc Optiray. Coronal and sagittal reformatted\n images were obtained.\n\n CT ABDOMEN: There is left lower lobe consolidation. Right basilar\n atelectasis is noted. There is a small right pleural effusion. Right hepatic\n cyst is again seen. The gallbladder, pancreas, spleen, adrenal glands, and\n kidneys are stable in appearance. There appears to be a horseshoe kidney.\n Cysts are again noted in the left limb. There are several wedge-shaped areas\n of hypoperfusion in the right limb which may represent infarcts, however\n pyelonephritis cannot be completely excluded. Stomach and bowel loops are\n unchanged in appearance. There is no free air. The amount of free fluid has\n significantly decreased. The lower thoracic/upper abdominal thrombosed\n dissection or intramural hematoma is unchanged in appearance. The celiac\n origin remains stenotic. Again seen is an SMA bypass. Thrombus within the\n more distal SMA is again seen. The re-implanted remains patent. It\n appears to fill the more proximal bowel in a retrograde fashion, however, the\n proximal portion of the marginal artery also appears thrombosed. This is also\n unchanged from prior exam. The amount of low attenuation fluid around the\n SMA, , and aortobifemoral is increased compared to prior exam. It\n also extends inferiorly along the left iliac limb. The majority of the fluid\n is superior to the isthmus of the horseshoe kidney.\n\n CT PELVIS: Foley catheter and air are noted in the bladder. There is sigmoid\n diverticulosis. The rectum is unremarkable. There is a small amount of free\n fluid. No pelvic or inguinal lymphadenopathy is identified. Iliac stents are\n noted in the native vessels. Skin staples are seen in both inguinal regions.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Stable appearance of SMA bypass , re-implantation, and\n aortobifemoral . Redemonstration of thrombus within the more distal SMA\n (Over)\n\n 12:33 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for ischemic appearing bowel, free air, and ta\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and marginal artery.\n 2. Interval increase in low-attenuation periaortic fluid compared to prior\n exam. Significant decrease in the amount of intraperitoneal fluid.\n 3. Left lower lobe consolidation which could represent atelectasis or\n pneumonia. Small right pleural effusion.\n 4. Wedge-shaped perfusion defects in the right limb of the horseshoe kidney\n which could represent infarcts, however, pyelonephritis cannot be excluded.\n 5. No definite evidence of bowel ischemia.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947210, "text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for Dobhoff tube placement in stomach\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass s/p re-intubation, now s/p Dobhoff\n placement\n REASON FOR THIS EXAMINATION:\n eval for Dobhoff tube placement in stomach\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man status post aortobifemoral bypass and\n reintubation now status post Dobbhoff placement.\n\n COMPARISON: Semi-upright portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: An endotracheal tube terminates 5 cm above\n the carina. A Dobhoff tube is seen with the tip in area of the stomach body.\n Right internal jugular central venous catheter terminates in the area of the\n right atrium. There is improved aeration of the right lower lobe since prior\n exam. Minimal right upper lung parenchymal opacities significantly improved\n since . Mild bibasilar atelectasis persists.\n\n IMPRESSION: Improved right lung aeration. Lines and tubes as indicated\n above.\n\n" }, { "category": "Radiology", "chartdate": "2152-02-09 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 948720, "text": " 5:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P AORTOBIFEM, WORSENING LEUKOCYTOSIS, HIGH MINUTE VENTILATION, TRACH VASCULOPATH EVAL FOR PE\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with high minute ventilation, trach, vasculopath\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: High minute ventilation, tracheostomy and vasculopath. Evaluate\n for pulmonary embolus or intra-abdominal process.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images through the chest were obtained before and\n after the intravenous administration of 100 cc of IV Optiray contrast. Delayed\n images through the abdomen and pelvis were then obtained. Coronal and\n sagittal reformatted images were generated.\n\n CTA OF THE CHEST: There is no evidence of acute thoracic aortic dissection.\n The descending thoracic aorta is unchanged in appearance inferiorly, with\n mural thrombus seen posteriorly within the lumen. There are coronary artery\n calcifications. There are no filling defects within the pulmonary arterial\n branches to suggest a pulmonary embolism. Some respiratory motion is present,\n degrading the image quality. There are small bilateral pleural effusions,\n decreased from and similar to those seen on . Lung\n windows demonstrate consolidated lung at the left basilar chest, increased\n from and similar to . Given the increase in\n opacification with concurrent decrease in the amount of pleural effusion, an\n infectious process is considered. There is thickening of the interlobular\n septa, suggestive of mild pulmonary edema. There are patchy opacities within\n the periphery of the lingula and within the right upper lobe, possibly\n suggesting a pneumonitis. There are two small nodular opacities which appear\n slightly more discrete, measuring about 4 mm (series 3, image 61) within the\n periphery of the lower right upper lobe. An endotracheal tube is in place,\n with the tip about 5 cm above the carina. The central airways are patent.\n There are no pathologically enlarged axillary lymph nodes. There are several\n chunky nodes of the mediastinum. The largest node is seen in the left\n paracarinal region (series 3, image 58), measuring 19 x 10 mm. Smaller lymph\n nodes are seen in the aortopulmonary window.\n\n CT OF THE ABDOMEN WITH CONTRAST: There is a rounded lesion within segment VI\n that is not fully characterized on this study but has been previously\n described as a cyst. On the current exam, it measures 27 Hounsfield units.\n The liver is otherwise unremarkable. There is vicarious excretion of contrast\n into the gallbladder. The spleen, pancreas and adrenal glands are stable in\n appearance. There appears to be a horseshoe kidney, as previously described.\n Several wedge shaped areas of hypoperfusion in the right limb are unchanged,\n (Over)\n\n 5:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P AORTOBIFEM, WORSENING LEUKOCYTOSIS, HIGH MINUTE VENTILATION, TRACH VASCULOPATH EVAL FOR PE\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n which may represent infarcts. Rounded hypodense lesions of the left limb are\n not fully characterized on this study.\n\n There is a moderate amount of free air within the abdomen, and there is a new\n gastrostomy tube in place. Free air appears to be related to this gastrostomy\n placement. Contrast opacifies small and large bowel loops down to the rectum.\n There is no obstruction. Free fluid in the abdomen has decreased compared to\n and may be slightly increased compared to .\n\n The appearance of the aorta is not significantly changed from .\n The lower thoracic/upper abdominal thrombosed dissection or intramural\n hematoma is unchanged in appearance. The celiac origin remains stenotic. The\n SMA bypass is again seen, thrombus within the more distal SMA is unchanged.\n The reimplanted remains patent. The amount of low attenuation fluid\n around the proximal aortobifemoral has increased from the prior exam\n (also increased from ). Low attenuation fluid around the SMA, \n and along the left iliac limb appears slightly increased from the prior study.\n Free fluid in the pelvis appears similar to . There is a Foley\n catheter within the bladder, and air within the bladder related to\n instrumentation. The prostate and seminal vesicles are unremarkable. Fluid\n surrounding the distal aspects of the aortobifemoral has slightly\n increased compared to both prior exams.\n\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.\n\n Multiplanar reformatted images were essential in delineating the anatomy and\n pathology in this case.\n\n IMPRESSION:\n 1. Interval increase in fluid surrounding the proximal and distal aspects of\n the aortobifemoral , compared to prior exams of and 11th.\n While fluid at these locales may represent postoperative collections,\n infection within these cannot be entirely excluded. Please correlate\n clinically.\n 2. Left lower lobe consolidation likely reflects pneumonia.\n 3. Element of superimposed pulmonary edema.\n 4. Interim placement of gastrostomy tube, with moderate free air related to\n this placement.\n 5. Patchy opacities in both lungs. Two more discrete nodular opacities are\n seen within the right upper lobe, measuring about 4 mm. CT followup could be\n considered if clinically indicated to evaluate stability.\n 6. Unchanged appearance of SMA bypass, thrombus within the more distal SMA,\n and unchanged appearance of reimplantation.\n 7. Wedge shaped perfusion defects in the right limb of the horseshoe kidney\n (Over)\n\n 5:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P AORTOBIFEM, WORSENING LEUKOCYTOSIS, HIGH MINUTE VENTILATION, TRACH VASCULOPATH EVAL FOR PE\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are unchanged, suggesting infarcts.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 947359, "text": " 8:57 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Eval. for dvt\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with pulmonary shunting.\n REASON FOR THIS EXAMINATION:\n Eval. for dvt\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Bilateral lower extremity duplex.\n\n INDICATION: Pulmonary shunting.\n\n FINDINGS: The right common femoral vein, right saphenofemoral junction, right\n superficial femoral vein, and right popliteal veins are all normal to\n compression and augmentation. The left common femoral vein, left\n saphenofemoral junction, left superficial femoral vein and left popliteal\n veins are all normal to compression and augmentation. No evidence of DVT in\n either lower extremity.\n\n IMPRESSION: No evidence of DVT in either lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947865, "text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man status post line removal.\n\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A right internal jugular central venous\n catheter has been removed. Left subclavian and Dobhoff catheters are in\n unchanged position. There is no pneumothorax. Interstitial edema is mildly\n improved in the interval. There is improved aeration at the left lung base,\n with persistent patchy and linear atelectasis. A moderately large right\n pleural effusion appears also slightly improved.\n\n IMPRESSION:\n 1. Status post removal of right internal jugular central venous catheter with\n no pneumothorax.\n 2. Interval improvement in interstitial edema.\n 3. Decreased right pleural effusion which remains small/moderate.\n 4. Improved aeration in left lung base.\n\n" }, { "category": "Radiology", "chartdate": "2152-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948379, "text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare to prior, eval for pna\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ABF, resp compromise\n\n REASON FOR THIS EXAMINATION:\n compare to prior, eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:15 A.M. \n\n HISTORY: Respiratory compromise. Suspect pneumonia.\n\n IMPRESSION: AP chest compared to through 11:\n\n In addition to mild generalized interstitial edema which has developed since\n there is greater opacification in the right lower lobe which may\n well be pneumonia. Heart is normal size, unchanged, and there is only a\n slight increase in the caliber of the azygos and mediastinal veins since\n . ET tube is in standard placement, left subclavian line tip\n projects over the junction of the brachiocephalic veins and a nasogastric tube\n passes into the stomach and out of view. No pneumothorax. Pleural effusion\n if any is mild.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948766, "text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ABF, resp compromise now trached\n\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male with respiratory compromise. Evaluate for\n infiltrate.\n\n Comparison is made to prior radiograph dated and prior CT\n examination dated .\n\n SINGLE PORTABLE ERECT UPRIGHT CHEST RADIOGRAPH.\n\n Since prior film, patient is now noted to be status post tracheostomy with tip\n of tracheostomy tube approximately 9 cm from the carina. Patient is markedly\n rotated towards the left on current film, but given these limitations, there\n appears to be slight improvement to right base opacity likely representing\n combination of edema and atelectasis. New areas of linear atelectasis are\n noted in the periphery of the left lobe and there is mild unchanged\n interstitial left-sided pulmonary edema. There is no evidence of\n pneumothorax. Left-sided subclavian central venous catheter remains unchanged\n in position and nasogastric tube have since been removed. Small pleural\n effusions noted on recent CT are not well appreciated on current radiograph.\n\n IMPRESSION:\n 1. Mild interstitial pulmonary edema.\n\n 2. Decreased right base opacity with improved visualization of hemidiaphragm.\n No new focal parenchymal consolidations are identified.\n\n" }, { "category": "Radiology", "chartdate": "2152-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947120, "text": " 3:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: appearance after bronchoscopy\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass s/p re-intubation for hypercarbia and\n somnolence\n REASON FOR THIS EXAMINATION:\n appearance after bronchoscopy\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:55 P.M. \n\n HISTORY: Aorto-bifem bypass. Hypercarbia.\n\n IMPRESSION: AP chest compared to 1:59 p.m. today:\n\n Right upper lobe consolidation improved substantially, right middle lobe\n atelectasis persists, moderate right pleural effusion stable. Mild pulmonary\n edema improved in the left lung. Heart size normal. Azygous distention\n suggests volume overload. ET tube and right internal jugular line in standard\n placements respectively.\n\n Overall sequence of changes suggests transient atelectasis due to airway\n secretions, volume overload, and improving mild pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-03 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 947772, "text": " 1:29 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: STROKE\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with concern for carotid artery disease/stroke.\n REASON FOR THIS EXAMINATION:\n r/o CAS - please do bedside in SICU if possible\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY.\n\n HISTORY: Possible stroke.\n\n FINDINGS: Duplex and color Doppler demonstrate minimal calcific plaque and\n wall thickening involving both carotid systems. The peak systolic velocities\n on the right are 66, 60 and 80 cm/sec for the ICA, CCA, and ECA respectively.\n Similar values in the left are 109, 66, and 68 cm/sec. The ICA/CCA ratio is\n 1.1 on the right and 1.7 on the left. There is antegrade flow involving the\n left vertebral artery, the right vertebral artery was not visualized due to an\n overlying dressing.\n\n IMPRESSION: Findings as stated above which indicate minimal bilateral\n plaque/wall thickening, no ICA stenosis on the right, left graded as less than\n 40%.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948096, "text": " 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for cardiopulm. abnormality\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with sudden onset a fib with RVR.\n\n REASON FOR THIS EXAMINATION:\n Eval. for cardiopulm. abnormality\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Atrial fibrillation.\n\n Single portable radiograph of the chest demonstrates a moderate left-sided\n pleural effusion, new when compared to . The remaining support lines\n are unchanged. The right costophrenic angle is excluded. Increased airspace\n opacities involving both lungs represent pulmonary edema. No pneumothorax.\n Trachea is midline. No frank consolidation is identified.\n\n IMPRESSION:\n\n Left-sided pleural effusion, new when compared to the previous study.\n\n Increased airspace opacities involving both lungs represent mild pulmonary\n edema.\n\n Support lines unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947333, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass s/p re-intubation for hypercarbia and\n somnolence\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:01 A.M. \n\n HISTORY: Reintubated for hypercarbia and somnolence.\n\n IMPRESSION: AP chest compared to through 5:\n\n Moderate right pleural effusion and atelectasis in the middle and lower lobe\n have worsened, comparable to the appearance on . Perihilar\n opacification in the left upper lung has been present for several days,\n probably pneumonia. Heart size is normal. ET tube and right internal jugular\n line are in standard placements and a feeding tube passes into the stomach and\n out of view. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946375, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate infiltrates\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass being treated for hospital acquired\n pneumonia\n REASON FOR THIS EXAMINATION:\n please evaluate infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:22 A.M., .\n\n HISTORY: Arterial bypass being treated for pneumonia.\n\n IMPRESSION: AP chest compared to through 29:\n\n Radiographic changes between and 26 are consistent with mild\n pulmonary edema, right middle and lower lobe collapse, basal atelectasis in\n the left lower lobe, and moderate right pleural effusion. Since ,\n right middle lobe and lower lobe have re-inflated and left lower lobe\n atelectasis has improved, moderate right pleural effusion has increased, and\n there is new opacification in the upper lungs progressing since .\n There is at least a component of mild pulmonary edema, but the severe apical\n consolidation suggest bilateral pneumonia. Heart is normal size, although\n increased slightly since , but mediastinal veins are not\n particularly dilated suggesting the patient is euvolemic. Right IJ line can\n be traced as far as the low SVC. No pneumothorax.\n\n Dr. was paged to report these findings at the time of dictation.\n\n" }, { "category": "Echo", "chartdate": "2152-01-20 00:00:00.000", "description": "Report", "row_id": 84086, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n68 yrs old for aortobifem BPG. Normal biventricular systolic function.\nImpaired diastolic function as Vp is 30cm/sec. But the IVRT is normal.\nThere is a contained old aortic dissection in the descending thoracic aorta\nbelow the subclavian take off. No flow throughn the dissection. There is a\nclass 4 atheroma in the distal arch of aorta.\nThe patient tolerated the aortic clamp well.\nMPI is 0.2 and did not change during the clamp and after the clamp.\n\n Billing error corrected. No changes made in findings. WJM\nLEFT ATRIUM: Normal LA size. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\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%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg).\nTransmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction.\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 aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch. Complex (>4mm) atheroma in the aortic arch.\nMildly dilated descending aorta. Descending aorta intimal flap/aortic\ndissection.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Three aortic\nvalve leaflets. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Prolonged (>250ms)\ntransmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging\nsuggests a normal left ventricular filling pressure (PCWP<12mmHg). Transmitral\nDoppler and tissue velocity imaging are consistent with Grade I (mild) LV\ndiastolic dysfunction. Right ventricular chamber size and free wall motion are\nnormal. The ascending aorta is mildly dilated. The aortic arch is mildly\ndilated. There are complex (>4mm) atheroma in the aortic arch. The descending\nthoracic aorta is mildly dilated. A mobile density is seen in the descending\naorta consistent with an intimal flap/aortic dissection. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. There are three aortic valve leaflets. Mild (1+) aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The transmitral flow propagation velocity is 0.3\nm/s (nl <=0.45m/s)\n\n\n" }, { "category": "Echo", "chartdate": "2152-01-20 00:00:00.000", "description": "Report", "row_id": 84087, "text": "PATIENT/TEST INFORMATION:\nIndication: Preoperative assessment.\nHeight: (in) 70\nWeight (lb): 150\nBSA (m2): 1.85 m2\nBP (mm Hg): 110/70\nStatus: Inpatient\nDate/Time: at 09:38\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. Normal\nregional LV systolic function. Low normal LVEF. TDI E/e' < 8, suggesting\nnormal PCWP (<12mmHg). No resting LVOT gradient. No VSD.\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. Mild (1+) 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. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate 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\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Regional left ventricular\nwall motion is normal. Overall left ventricular systolic function is low\nnormal (LVEF 50%) secondary to akinesis of the basal segment of the inferior\nfree wall and mild hypokinesis of the posterior wall. Tissue Doppler imaging\nsuggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Trivial mitral regurgitation is\nseen. The pulmonary artery systolic pressure could not be determined. There is\nno pericardial effusion.\n\nImpression: inferior (basal) infarct with preserved left ventricular ejection\nfraction\n\n\n" }, { "category": "ECG", "chartdate": "2152-02-04 00:00:00.000", "description": "Report", "row_id": 207644, "text": "Sinus rhythm\nSupraventricular extrasystoles\nShort PR interval\nPossible inferior infarct - age undetermined\nSince previous tracing, ventricular premature complex not seen, peaked anterior\nT wave, QT-C shorter, consider hyperkalemia\n\n" }, { "category": "ECG", "chartdate": "2152-01-18 00:00:00.000", "description": "Report", "row_id": 207645, "text": "Sinus rhythm with PVCs\nPossible inferior infarct - age undetermined\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2152-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945632, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval inf\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with aortobifem bypass\n\n REASON FOR THIS EXAMINATION:\n eval inf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortobifemoral bypass. Evaluate for infiltrates.\n\n COMPARISON: .\n\n CHEST AP: The tip of the endotracheal tube is 6 cm above the carina.\n Swan-Ganz catheter terminates in the right main pulmonary artery. There is\n stable left pleural effusion and mild left basilar atelectasis. Pulmonary\n edema. Tip of the NG tube is in the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 945584, "text": " 4:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX and check new line position\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with aortobifem bypass\n REASON FOR THIS EXAMINATION:\n r/o PTX and check new line position\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:02 P.M. ON .\n\n HISTORY: Bypass graft. Rule out pneumothorax.\n\n IMPRESSION: AP chest compared to .\n\n Tip of a new Swan-Ganz catheter inserted through right jugular introducer\n projects over the right pulmonary artery. No pneumothorax or mediastinal\n widening. Lung volumes are lower, with a severe left lower lobe atelectasis\n and pneumoperitoneum reflecting recent abdominal surgery. There is no\n pneumothorax. Mild interstitial edema is present. ET tube is in standard\n placement and the nasogastric tube ends in the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945763, "text": " 10:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for CHF\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with aortobifem bypass now worsening resporatory\n status\n REASON FOR THIS EXAMINATION:\n please eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE-VIEW CHEST\n\n INDICATION: Aortobifem bypass with worsening respiratory status. Assess for\n CHF.\n\n COMPARISON: Earlier, same day 5 a.m.\n\n FINDINGS: Single bedside upright exam demonstrates interval removal of the\n endotracheal tube. The nasogastric tube tip overlies the stomach, as before.\n Right internal jugular central venous line containing Swan-Ganz catheter tip\n projects over the right main pulmonary artery, unchanged. There has been\n interval increase in size of right greater than left pleural effusions.\n Pulmonary vasculature is indistinct. Lung volumes are low.\n\n IMPRESSION: New moderate right-sided pleural effusion and mild-moderate\n pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2152-01-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945896, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inc wbc, infiltrate?\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with aortobifem bypass now worsening resporatory\n status\n REASON FOR THIS EXAMINATION:\n inc wbc, infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 05:08\n\n INDICATION: Worsening dyspnea.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior study, there is increased patchiness in a\n paracentral distribution bilaterally. This is associated with some increased\n density of right pleural fluid, and the constellation of findings suggest\n worsening in fluid status with CHF. In addition, some additional patchiness\n is seen in the left lower lung field adjacent to the heart.\n\n IMPRESSION: The constellation of findings suggest a left lower lobe pneumonia\n which may have triggered CHF. Lines and tubes remain in place with no PTX.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 945291, "text": " 7:03 PM\n CHEST (PA & LAT) Clip # \n Reason: ?chf\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with mesentric ischemia\n REASON FOR THIS EXAMINATION:\n ?chf\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n PA and lateral upright chest radiograph was reviewed. The heart size is\n normal. The mediastinum has normal position, contour and width. The lungs\n are clear. There is no pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946012, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: etiology desat\n Admitting Diagnosis: MESENTERIC ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p aortobifem bypass\n REASON FOR THIS EXAMINATION:\n etiology desat\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:49 A.M. ON .\n\n HISTORY: Arterial bypass. Desaturated.\n\n IMPRESSION: AP chest compared to through 28:\n\n Multifocal pulmonary consolidation has progressed substantially since , consistent with widespread pneumonia, middle lobe collapse persists, while\n right lower lobe collapse and interstitial edema have improved. Heart is\n normal size. There is probably a small to moderate amount of right pleural\n effusion. No pneumothorax. Dr. was paged to report these findings, at\n the time of dictation.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558217, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.3\nC (95.5\n HR: 71 (70 - 71) bpm\n BP: 125/53(71) {77/40(51) - 125/59(71)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,872 mL\n PO:\n TF:\n IVF:\n 1,872 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, 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, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 141 K/uL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 72 year old male with pmh CHF, CKD, s/p recent hospitalization for\n upper GI bleeding w/ recent cauterization and hyperthyroidism amio,\n now presenting with fever and leukocytosis.\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source.\n - U/S guided paracentesis\n - Vanc/zosyn\n - F/U cultures\n #Hypotension: Likely from sepsis or dehydration. Now at baseline BP of\n 110/50.\n - vanc, zosyn\n - fluids\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF. Now improving\n - Follow creat\n - IVF to maintain UOP\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation or intraabdominal process.\n - Follow LFTs\n #Atrial Fibrillation: Will continue with amiodarone and digoxin.\n Holding warfarin given INR 3.3. Good rate control.\n #Thyrotoxicosis: Induced by amiodarone. Continuing amiodarone because\n benefits of controlling a-fib outweigh harms of potentiating\n thyrotoxicosis. On prednisone for symptom control.\n - Stress dose steroids in setting of acute illness.\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Echo", "chartdate": "2129-02-17 00:00:00.000", "description": "Report", "row_id": 86881, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease.\nHeight: (in) 71\nWeight (lb): 215\nBSA (m2): 2.18 m2\nBP (mm Hg): 116/52\nHR (bpm): 70\nStatus: Outpatient\nDate/Time: at 10:01\nTest: 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 ATRIUM: LA volume markedly increased (>32ml/m2). Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\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: Dilated RV cavity. RV function depressed. Abnormal septal\nmotion/position consistent with RV pressure/volume overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild thickening of mitral valve chordae. of\nthe mitral chordae (normal variant). No resting LVOT gradient. Calcified tips\nof papillary muscles. Mild (1+) MR. Prolonged (>250ms) transmitral E-wave\ndecel time.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Moderate to severe [3+] TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent ventricular premature beats.\n\nConclusions:\nThe left atrial volume is markedly increased (>32ml/m2). The left atrium is\ndilated. The right atrium is markedly dilated. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%). There is no ventricular septal defect. The right ventricular cavity is\ndilated with depressed free wall contractility. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. No mass or vegetation is\nseen on the mitral valve. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. Moderate to severe [3+]\ntricuspid regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Dilated, hypokinetic right ventricle with moderate to severe\ntricuspid regurgitation and moderate pulmonary hypertension. No evidence of\nendocarditis (cannot exclude). Severe biatrial enlargement.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2129-02-08 00:00:00.000", "description": "Report", "row_id": 86882, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 72\nWeight (lb): 190\nBSA (m2): 2.09 m2\nBP (mm Hg): 110/50\nHR (bpm): 69\nStatus: Outpatient\nDate/Time: at 12:00\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 catheter or pacing\nwire is seen in the RA and extending into the RV. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function\ndepressed. Abnormal diastolic septal motion/position consistent with RV volume\noverload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNo TS. Moderate to severe [3+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: If clinically indicated, a transesophageal echocardiographic\nexamination is recommended. Left pleural effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is markedly dilated. The\nestimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness,\ncavity size and regional/global systolic function are normal (LVEF 70%).\nTissue Doppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). There is no ventricular septal defect. The right ventricular\ncavity is dilated with depressed free wall contractility. There is abnormal\ndiastolic septal motion/position consistent with right ventricular volume\noverload. The ascending aorta is mildly dilated. The aortic arch is mildly\ndilated. There are focal calcifications in the aortic arch. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate to severe [3+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. No vegetation/mass is seen on the\npulmonic valve. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , right heart volume overload is increased.\n\nIf clinically indicated, a transesophageal echocardiographic examination is\nrecommended.\n\nIMPRESSION: no definite vegetations seen\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 558123, "text": "Chief Complaint: Fever, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72 yr old recently discharged from hospital following UGI bleed and\n amiodarone induced thryotoxicosis. Had EGD with cauterization of\n several gastric sites of bleeding. Since discharge on did well\n until when endocrinologist stopped methimazole and theophylline.\n Has felt poorly since then. Awoke yesterday morning feeling tired. Had\n sycnopal episode. Was taken by ambulance to local hospital; reportedly\n had temp to 104 before going to hospital.\n Taken to hospital in , MA. Was found to be hypotensive to the\n 80's with WBC 20K. Given Vanco and Zosyn and 2L of IV fluid and was\n transferred to ED. In ED, BP was in 80's with good O2 sat on room\n air. In ED temp to 101.5. Given additional 2L of fluid; BP came up to\n 115 systolic.\n Patient also complaining of left shoulder and chest pain near site of\n pacemaker (pacer for complete heart block). Some chest tightness and\n had vomiting this AM (has had this intermittently for one month). Mild\n chest congestion with a recent \"cold.\" Patient had pacer infection\n with change in .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n CHF - Echo from with LVEF 55-60% , LVH, moderately dilated RV,\n 2+ tricuspid regurg\n Afib on coumadin\n CRF - baseline creat 2.0\n UGI bleed\n s/p pacemaker for complete heart block\n Hypertension\n DM, type II\n Hyperthyroidism recently diagnosed\n Chronic anemia, hct mid 20s\n Diverticulosis (?)\n Barrett's esophagus\n Meds at home: coumadin, spironolactone, avapro, digoxin, prednisone\n (for thyotoxicosis), protonix, insulin, amiodarone\n Negative for thyroid disease\n Positive for DM in sisters\n Father with pancreatic ca\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married\n Review of systems:\n Flowsheet Data as of 02:18 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: 36.8\nC (98.2\n HR: 71 (71 - 71) bpm\n BP: 114/56(69) {114/56(69) - 114/56(69)} mmHg\n RR: 19 (16 - 19) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, 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, Dry oral mucosa\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic), I-II/VI systolic murmur at LSB; no radiation\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , Dullness : right > left base), (Breath\n Sounds: No(t) Clear : , Crackles : Few at bases, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 3+ edema, Left: 3+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 131\n 25.5\n 130\n 3.3\n 109\n 23\n 95\n 4.9\n 129\n 19.2\n [image002.jpg]\n Other labs: PT / PTT / INR://3.5, ALT / AST:51/49, Alk Phos / T\n Bili:80/1.6, Differential-Neuts:91, Lactic Acid:1.5\n Fluid analysis / Other labs: troponin .07\n digoxin 1.05\n UA negative\n Imaging: Abd ultrasound: negative for biliary obstruction. +/- mild\n edema of gall bladder wall\n CT abd/pelvis: moderate free fluid in the abdomen and pelvis\n (predominantly left side). Basilar atelectasis (small) bilaterally\n CXR: supine film. No focal infiltrates; no effusions. Mild prominence\n of central vasculature\n Assessment and Plan\n FEVER\n HYPOTENSION\n Chronic renal failure\n Acute renal failure\n ANEMIA\n THYROTOXICOSIS\n AFIB\n Patient with fever, significant leukocytosis and hypotension consistent\n with bacterial infection. Electrolytes also suggestive of volume\n depletion. Patient needs additional fluids; would place Foley cath to\n allow better monitoring of his urine output in the setting of acute on\n chronic renal failure. Neck veins appear elevated, but patient has none\n right heart failure and these pressures likely do not accurately\n reflect left sided filling pressures. If he has diastolic dysfunction\n of the left ventricle, he may be more pre-load dependent in the setting\n of low systemic vascular resistance. The cause of the chronic right\n systolic heart failure is unclear; he has no clear pulmonary history.\n If renal function improves, would consider CTA to assess for chronic\n thromboembolic diease, although the patient has been on chronic\n coumadin making this unlikely. Source of infection unclear. With fluid\n in abdomen, concern about possible intestinal perforation (possibly\n divertiulum) although his exam is quite benign. Patient should have\n ultrasound guided paracentesis tomorrow. Being vanco and zosyn tonight\n pending cultures. Patient has chronic cough, but no obvious acute\n intrapulmonary process at this time.\n Renal failure reflects acute on chronic process; likely pre-renal\n azotemia. Fliuds and close monitoring of urine output required. Vanco\n to be dosed by levels pending improvement in renal function.\n Blood pressure remains low but patient mentating well and making urine.\n Lactate level is low. Continue to support with crystalloid for now.\n Oxygenation good. Suspect low SVR related to infection and volume\n depletion contributing to low pressure.\n Afib is chronic. Good rate control now.\n Hct low, but near baseline. Monitor stool guaiac. Not at transfusion\n threshold now, but with fluids that he is getting, I would recheck Hct\n now; may need transfusion.\n Hyponatremia likely related to CHF and diuretics. Patient getting NS\n now. Recheck electrolytes.\n ICU Care\n Nutrition: oral\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 12:44 AM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558139, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Neuro: alert and oriented, afebrile, mild c/o abdominal pain requiring\n no pain meds.\n Resp: LSC, 4L NC, O2 sat 98-100%.\n CV: hypotensive to 80s, 500cc NS bolus given. An additional 1L LRx1\n given. BP in 100s. HR 70, AV paced. No c/o dizziness. EKG done.\n GI/GU: +BS, OOB to commode stoolx2, voiding in urinal. Tolerating POs.\n Insulin sliding scale.\n" }, { "category": "General", "chartdate": "2129-02-04 00:00:00.000", "description": "Generic Note", "row_id": 558207, "text": "TITLE:\n Chief Complaint: Fever, leukocytosis\n 24 Hour Events:\n overnight, pt quiet. No issues\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Neurologic: No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:58 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: 71 (70 - 71) bpm\n BP: 95/53(64) {77/40(51) - 114/56(70)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,860 mL\n PO:\n TF:\n IVF:\n 1,860 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,660 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis\n Skin: Warm, spider angiomas on chest\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 141 K/uL\n 9.8 g/dL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n Assessment and Plan: 72 year old male with pmh CHF, CKD, upper GI\n bleeding w/ recent cauterization, presenting with fever and\n leukocytosis.\n .\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source. Though\n abdomen is non-tender, and CT scan does not show free air, will cover\n for GI source given recent cauterization and intrabdominal fluid.\n Given recent hospitalization will cover for MRSA and pseudomonas.\n Possibly from SBP. consider US guided tap of fluid.\n -vancomycin\n -zosyn\n -f/u cultures\n .\n #Hypotension: Likely from severe sepsis, Baseline BP 110/50. Will\n continue with fluid resuscitation, maintain MAP > 60. continue abx.\n -vanc, zosyn\n -fluids\n .\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF. Will check U lytes, administer fluid, hold diuretics.\n -hold spironolactone, torsemide\n -IVF\n -U lytes\n .\n #Chest Pain: Lilkely musculoskeletal, but given vague history will\n trend enzymes. ekg difficult to interpret in setting of V-pacing.\n .\n #Atrial Fibrillation: will continue with amiodarone and digoxin.\n Holding warfarin given INR 3.3.\n .\n #CHF: Mild symmetric LVH with EF 55-60%, along with moderatelt dilated\n RV w/ tricuspid regurgitation. Will hold avapro, spironolactone, and\n torsemide in setting of hypotension. will continue digoxin.\n -hold avapro, torsemide, spironolactone\n -continue digoxin.\n .\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation. will trend.\n -follow LFTs\n .\n #Thyrotoxicosis: Induced by amiodarone. Continuing amiodarone because\n benefits of controlling a-fib outweigh harms of potentiating\n thyrotoxicosis. Plan is to control symptoms with prednisone, however,\n will hold prednisone in setting of acute infection.\n -hold prednisone 20mg PO BID.\n .\n #Anemia:Likely from chronic kidney disease. Also in setting of\n supratherapeutic INR, it's possible intrabdominal fluid is blood. will\n continue to trend hematocrit.\n .\n #Barrett's esophogus: protonix 40mg PO BID.\n .\n #Diabetes: continue home insulin regimen\n .\n #) Prophylaxis: PPI, supratherapeutic INR, bowel regimen, pneumoboots.\n .\n #) FEN: diabetic low salt diet\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558211, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.3\nC (95.5\n HR: 71 (70 - 71) bpm\n BP: 125/53(71) {77/40(51) - 125/59(71)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,872 mL\n PO:\n TF:\n IVF:\n 1,872 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, 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, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 141 K/uL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n Patient with fever, significant leukocytosis and hypotension consistent\n with bacterial infection. Electrolytes also suggestive of volume\n depletion. Patient needs additional fluids; would place Foley cath to\n allow better monitoring of his urine output in the setting of acute on\n chronic renal failure. Neck veins appear elevated, but patient has none\n right heart failure and these pressures likely do not accurately\n reflect left sided filling pressures. If he has diastolic dysfunction\n of the left ventricle, he may be more pre-load dependent in the setting\n of low systemic vascular resistance. The cause of the chronic right\n systolic heart failure is unclear; he has no clear pulmonary history.\n If renal function improves, would consider CTA to assess for chronic\n thromboembolic diease, although the patient has been on chronic\n coumadin making this unlikely. Source of infection unclear. With fluid\n in abdomen, concern about possible intestinal perforation (possibly\n divertiulum) although his exam is quite benign. Patient should have\n ultrasound guided paracentesis tomorrow. Being vanco and zosyn tonight\n pending cultures. Patient has chronic cough, but no obvious acute\n intrapulmonary process at this time.\n Renal failure reflects acute on chronic process; likely pre-renal\n azotemia. Fliuds and close monitoring of urine output required. Vanco\n to be dosed by levels pending improvement in renal function.\n Blood pressure remains low but patient mentating well and making urine.\n Lactate level is low. Continue to support with crystalloid for now.\n Oxygenation good. Suspect low SVR related to infection and volume\n depletion contributing to low pressure.\n Afib is chronic. Good rate control now.\n Hct low, but near baseline. Monitor stool guaiac. Not at transfusion\n threshold now, but with fluids that he is getting, I would recheck Hct\n now; may need transfusion.\n Hyponatremia likely related to CHF and diuretics. Patient getting NS\n now. Recheck electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:44 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 Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558215, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.3\nC (95.5\n HR: 71 (70 - 71) bpm\n BP: 125/53(71) {77/40(51) - 125/59(71)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,872 mL\n PO:\n TF:\n IVF:\n 1,872 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, 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, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 141 K/uL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 72 year old male with pmh CHF, CKD, upper GI bleeding w/ recent\n cauterization, presenting with fever and leukocytosis.\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source.\n - U/S guided paracentesis\n - Vanc/zosyn\n - F/U cultures\n #Hypotension: Likely from sepsis or dehydration. Now at baseline BP of\n 110/50.\n - vanc, zosyn\n - fluids\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF. Now improving\n - Follow creat\n - IVF to maintain UOP\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation or intraabdominal process.\n - Follow LFTs\n #Atrial Fibrillation: will continue with amiodarone and digoxin.\n Holding warfarin given INR 3.3.\n #Thyrotoxicosis: Induced by amiodarone. Continuing amiodarone because\n benefits of controlling a-fib outweigh harms of potentiating\n thyrotoxicosis. On prednisone for symptom control.\n - Stress dose steroids in setting of acute illness.\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Boots, Coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558218, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.3\nC (95.5\n HR: 71 (70 - 71) bpm\n BP: 125/53(71) {77/40(51) - 125/59(71)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,872 mL\n PO:\n TF:\n IVF:\n 1,872 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, 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, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 141 K/uL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 72 year old male with pmh CHF, CKD, s/p recent hospitalization for\n upper GI bleeding w/ recent cauterization and hyperthyroidism amio,\n now presenting with fever and leukocytosis.\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source.\n - U/S guided paracentesis\n - Vanc/zosyn\n - F/U cultures\n #Hypotension: Likely from sepsis or dehydration. Now at baseline BP of\n 110/50.\n - vanc, zosyn\n - fluids\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF. Now improving\n - Follow creat\n - IVF to maintain UOP\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation or intraabdominal process.\n - Follow LFTs\n #Atrial Fibrillation: Will continue with amiodarone and digoxin.\n Holding warfarin given INR 3.3. Good rate control.\n #Thyrotoxicosis: Induced by amiodarone. On prednisone at home for\n symptom control.\n - Holding steroids\n - Discuss amio with endo/cards and come to a consensus\n - Evaluate for other causes of 50# weight loss\n - Repeat TFTs\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 558133, "text": "Chief Complaint: Fatigue\n HPI:\n This is a 72M w/ pmh CHF, a-fib on warfarin, ckd baseline Cr 2.2,\n presenting with two days of fatigue. He reports waking yesterday\n morning, and when he got out of bed he syncopized. He is unsure how\n long he was unconscious for. He reports his wife found him from the\n floor and called an ambulance. Prior to the ambulance arriving his\n temperature was measured at home and found to be 104. He was brought\n to hospital where he was complaining of fatigue, poor\n appetite, and left sided shoulder, and chest pain, worse with movement\n of his arm. He was hypotensive with sbp in the 80's. he had a white\n count which was 20, and an abdominal US which showed intraabdominal\n fluid and mildly thickened gallbladder. He was given 3L of NS, and\n started on vancomycin and zosyn.\n .\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n .\n On ROS, he reports chest congestion, and occasional vomiting over the\n past month. He denied dysuria or diahrrea. He denied shortness of\n breath, orthopnea, or PND.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Warfarin 5 mg Tablet PO daily\n Spironolactone 25 mg Tablet PO BID\n Avapro 150 mg Tablet PO daily\n Digoxin 125 mcg Tablet PO QOD\n Prednisone 20 mg Tablet PO BID\n Torsemide 20 mg Tablet PO BID\n Pantoprazole 40 mg Tablet, Delayed Release PO BID\n Insulin NPH 14 units qam\n Humalog Pen 100 unit/mL per sliding scale\n Amiodarone 200 mg Tablet PO daily\n Past medical history:\n Family history:\n Social History:\n Chronic CHF LVEF 55-60%\n Atrial fibrillation on coumadin\n CHB s/p PPM/AICD\n Type II Diabetes mellitus\n Chronic Kidney Disease (baseline creatinine 2.2)\n Chronic anemia\n Degenerative disc disease\n s/p L inguinal repair\n Upper GI bleeding, found to have Barrett's esophogus and gastric antral\n vascular ectasia \n Amiodarone induced thyrotoxicosis\n Father died of pancreatic cancer\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain, Edema, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, left shoulder pain\n Integumentary (skin): Rash, spider angioma\n Flowsheet Data as of 03:43 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: 36.8\nC (98.2\n HR: 70 (70 - 71) bpm\n BP: 109/53(67) {85/40(51) - 114/56(70)} mmHg\n RR: 18 (16 - 20) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 717 mL\n PO:\n TF:\n IVF:\n 717 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 517 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Vitals: 97.8 100/53 70 17 100% RA,\n General: Awake, alert, NAD.\n HEENT: hyperpigmented purple nodule on forhead. EOMI without nystagmus,\n no scleral icterus noted, MM dry,\n Neck: JVP to angle of jaw\n Pulmonary: crackles at left base\n Cardiac: RRR, nl. S1S2, 2/6 systolic murmur at LLSB\n Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: 3+ edema b/l\n Skin: spider angiomata over chest\n Labs / Radiology\n 141 K/uL\n 9.8 g/dL\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n \n 2:33 A2/20/ 02:41 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Imaging: TTE :\n IMPRESSION: LVEF 55-60%. Dilated right ventricle with borderline\n systolic\n function. Mild symmetric left ventricular hypertrophy with\n preserved global and regional systolic function. Moderate\n tricuspid regurgitation. Moderate pulmonary hypertension.\n .\n Radiologic Data:\n Abdomen CT:\n Moderate free fluid in the abdomen and pelvis, though does not appear\n completely simple base on attenuation values. No definite source.\n Metallic density in stomach near GE junction may related to recent\n endoscopy and cauterization\n .\n Head CT: No intracranial Hemorrhage\n .\n CXR: No cardiopulmonary process.\n .\n Abd U/S (OSH, reviewed with our radiologist): no intra-\n or extrahepatic ductal dilatation. CBD 5mm. Gallbladder wall may\n be slightly edematous, but in the setting of free fluid in the\n abdomen has unclear significance. gallbladder not distended. no\n gall stones.\n .\n EGD: Barrett's esophagus. Small amount of clotted and\n maroon-colored blood was seen in the whole stomach. Gastric\n antral vascular ectasia. Three punctate flat lesions in the\n stomach fundus with mild oozing of blood were noted. These\n lesions were treated successfully with -Cap until hemostasis\n was achieved.\n Assessment and Plan\n Assessment and Plan: 72 year old male with pmh CHF, CKD, upper GI\n bleeding w/ recent cauterization, presenting with fever and\n leukocytosis.\n .\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source. Though\n abdomen is non-tender, and CT scan does not show free air, will cover\n for GI source given recent cauterization and intrabdominal fluid.\n Given recent hospitalization will cover for MRSA and pseudomonas.\n Possibly from SBP. consider US guided tap of fluid.\n -vancomycin\n -zosyn\n -f/u cultures\n .\n #Hypotension: Likely from severe sepsis, Baseline BP 110/50. Will\n continue with fluid resuscitation, maintain MAP > 60. continue abx.\n -vanc, zosyn\n -fluids\n .\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF. Will check U lytes, administer fluid, hold diuretics.\n -hold spironolactone, torsemide\n -IVF\n -U lytes\n .\n #Chest Pain: Lilkely musculoskeletal, but given vague history will\n trend enzymes. ekg difficult to interpret in setting of V-pacing.\n .\n #Atrial Fibrillation: will continue with amiodarone and digoxin.\n Holding warfarin given INR 3.3.\n .\n #CHF: Mild symmetric LVH with EF 55-60%, along with moderatelt dilated\n RV w/ tricuspid regurgitation. Will hold avapro, spironolactone, and\n torsemide in setting of hypotension. will continue digoxin.\n -hold avapro, torsemide, spironolactone\n -continue digoxin.\n .\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation. will trend.\n -follow LFTs\n .\n #Thyrotoxicosis: Induced by amiodarone. Continuing amiodarone because\n benefits of controlling a-fib outweigh harms of potentiating\n thyrotoxicosis. Plan is to control symptoms with prednisone, however,\n will hold prednisone in setting of acute infection.\n -hold prednisone 20mg PO BID.\n .\n #Anemia:Likely from chronic kidney disease. Also in setting of\n supratherapeutic INR, it's possible intrabdominal fluid is blood. will\n continue to trend hematocrit.\n .\n #Barrett's esophogus: protonix 40mg PO BID.\n .\n #Diabetes: continue home insulin regimen\n .\n #) Prophylaxis: PPI, supratherapeutic INR, bowel regimen, pneumoboots.\n .\n #) FEN: diabetic low salt diet\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558160, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Neuro: alert and oriented, afebrile, mild c/o abdominal pain requiring\n no pain meds.\n Resp: LSC, 4L NC, O2 sat 98-100%.\n CV: hypotensive to 80s, 500cc NS bolus given. An additional 1L LRx1\n given. BP in 90-100s. HR 70, AV paced. No c/o dizziness. EKG done.\n GI/GU: +BS, OOB to commode stoolx2, voiding in urinal. Tolerating POs.\n Insulin sliding scale.\n" }, { "category": "Physician ", "chartdate": "2129-02-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558270, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.3\nC (95.5\n HR: 71 (70 - 71) bpm\n BP: 125/53(71) {77/40(51) - 125/59(71)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,872 mL\n PO:\n TF:\n IVF:\n 1,872 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, 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, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 141 K/uL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n 72 year old male with pmh CHF, CKD, s/p recent hospitalization for\n upper GI bleeding w/ recent cauterization and hyperthyroidism amio,\n now presenting with fever and leukocytosis.\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source.\n - U/S guided paracentesis by IR today\n - Vanc/zosyn\n - F/U cultures\n #Hypotension: Likely from sepsis or dehydration. Now at baseline BP of\n 110/50.\n - vanc, zosyn\n - fluids\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF. Now improving\n - Follow creat\n - IVF to maintain UOP\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation or intraabdominal process.\n - Follow LFTs\n #Atrial Fibrillation: Will continue with amiodarone and digoxin.\n Holding warfarin given INR 3.3. Good rate control.\n #Thyrotoxicosis: Induced by amiodarone. On prednisone at home for\n symptom control.\n - Holding steroids till abdominal concerns for sepsis wane, then\n restart later today/ tomorrow\n - Discuss amio with endo/cards and come to a consensus\n - Evaluate for other causes of 50# weight loss\n - Repeat TFTs\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558260, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Hypotension (not Shock)\n Assessment:\n BP range since adm 77-125/45-53, some periods of hypotension overnight\n with a low of 77/45, pt received 1.5L of fluid overnight with good BP\n response, blood and urine cultures sent results pending, received vanc\n and zosyn overnight\n Action:\n Pt has been maintaining BP with systolic >100, baseline BP 110/50, pt\n continues to report extreme thirst at times, has voided x3, refused\n foley overnight, taking Pos well\n Response:\n Maintaining adequate BP with minimal fluid resuscitation, pt fluid\n balance about net even for LOS\n Plan:\n Encourage Po intake, continue to monitor I/O, continue to monitor BP,\n provide fluid as needed, f/u culture data, continue antibiotics as\n ordered\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt reporting abd pain on admission, pt also reporting pain in the left\n upper chest at site of pacer, abd resolved following bm, pt continues\n to intermittently report pain at site of pacer, CE sent, trop flat, EKG\n AV paced, pt is receiving home doses of digoxin and amiodarone\n Action:\n Monitoring, low-sodium diet as tolerated, abd u/s to evaluate for\n ascites, acetaminophen 325mg given for pain\n Response:\n Ascites insufficient for tapping, pt reporting some relief for pain\n with acetaminophen adm, continues to deny abd pain\n Plan:\n Continue to monitor, f/u culture data, acetaminophen as needed for pain\n control\n Hyperthyroidism\n Assessment:\n Pt with visible on exam, known thyrotoxitosis r/t amiodarone\n dosing\n Action:\n Cards consulted, pt to continue on amiodarone at this time\n Response:\n Ongoing\n Plan:\n Continue amiodarone at this time, continue to monitor thyroid function\n with am labs, consider restarting pt\ns prednisone dosing if ? of\n infection ruled out\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558261, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Hypotension (not Shock)\n Assessment:\n BP range since adm 77-125/45-53, some periods of hypotension overnight\n with a low of 77/45, pt received 1.5L of fluid overnight with good BP\n response, blood and urine cultures sent results pending, received vanc\n and zosyn overnight\n Action:\n Pt has been maintaining BP with systolic >100, baseline BP 110/50, pt\n continues to report extreme thirst at times, has voided x3, refused\n foley overnight, taking Pos well\n Response:\n Maintaining adequate BP with minimal fluid resuscitation, pt fluid\n balance about net even for LOS\n Plan:\n Encourage Po intake, continue to monitor I/O, continue to monitor BP,\n provide fluid as needed, f/u culture data, continue antibiotics as\n ordered\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt reporting abd pain on admission, pt also reporting pain in the left\n upper chest at site of pacer, abd resolved following bm, pt continues\n to intermittently report pain at site of pacer, CE sent, trop flat, EKG\n AV paced, pt is receiving home doses of digoxin and amiodarone\n Action:\n Monitoring, low-sodium diet as tolerated, abd u/s to evaluate for\n ascites, acetaminophen 325mg given for pain\n Response:\n Ascites insufficient for tapping, pt reporting some relief for pain\n with acetaminophen adm, continues to deny abd pain\n Plan:\n Continue to monitor, f/u culture data, acetaminophen as needed for pain\n control\n Hyperthyroidism\n Assessment:\n Pt with visible on exam, known thyrotoxitosis r/t amiodarone\n dosing\n Action:\n Cards consulted, pt to continue on amiodarone at this time\n Response:\n Ongoing\n Plan:\n Continue amiodarone at this time, continue to monitor thyroid function\n with am labs, consider restarting pt\ns prednisone dosing if ? of\n infection ruled out\n Demographics\n Attending MD:\n \n Admit diagnosis:\n FEVER;ABDOMINAL PAIN\n Code status:\n Full code\n Height:\n Admission weight:\n 1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, GI Bleed\n CV-PMH: CHF, Hypertension, Pacemaker\n Additional history: Afib on coumadin, complete heart block w/ pacer,\n chronic kidney disease, degenerative disc disease, diverticulosis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:50\n Temperature:\n 96.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,892 mL\n 24h total out:\n 1,760 mL\n Pertinent Lab Results:\n Sodium:\n 127 mEq/L\n 02:41 AM\n Potassium:\n 4.5 mEq/L\n 02:41 AM\n Chloride:\n 94 mEq/L\n 02:41 AM\n CO2:\n 20 mEq/L\n 02:41 AM\n BUN:\n 101 mg/dL\n 02:41 AM\n Creatinine:\n 3.0 mg/dL\n 02:41 AM\n Glucose:\n 373\n 12:00 PM\n Hematocrit:\n 29.0 %\n 02:41 AM\n Finger Stick Glucose:\n 244\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\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/\n Transferred to: 11R\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558256, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Hypotension (not Shock)\n Assessment:\n BP range since adm 77-125/45-53, some periods of hypotension overnight\n with a low of 77/45, pt received 1.5L of fluid overnight with good BP\n response, blood and urine cultures sent results pending, received vanc\n and zosyn overnight\n Action:\n Pt has been maintaining BP with systolic >100, baseline BP 110/50, pt\n continues to report extreme thirst at times, has voided x3, refused\n foley overnight, taking Pos well\n Response:\n Maintaining adequate BP with minimal fluid resuscitation, pt fluid\n balance about net even for LOS\n Plan:\n Encourage Po intake, continue to monitor I/O, continue to monitor BP,\n provide fluid as needed, f/u culture data, continue antibiotics as\n ordered\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt reporting abd pain on admission, pt also reporting pain in the left\n upper chest at site of pacer, abd resolved following bm, pt continues\n to intermittently report pain at site of pacer, CE sent, trop flat, EKG\n AV paced, pt is receiving home doses of digoxin and amiodarone\n Action:\n Monitoring, low-sodium diet as tolerated, abd u/s to evaluate for\n ascites, acetaminophen 325mg given for pain\n Response:\n Ascites insufficient for tapping, pt reporting some relief for pain\n with acetaminophen adm, continues to deny abd pain\n Plan:\n Continue to monitor, f/u culture data, acetaminophen as needed for pain\n control\n Hyperthyroidism\n Assessment:\n Pt with visible on exam, known thyrotoxitosis r/t amiodarone\n dosing\n Action:\n Cards consulted, pt to continue on amiodarone at this time\n Response:\n Ongoing\n Plan:\n Continue amiodarone at this time, continue to monitor thyroid function\n with am labs, consider restarting pt\ns prednisone dosing if ? of\n infection ruled out\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558242, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Hypotension (not Shock)\n Assessment:\n BP range since adm 77-125/45-53, some periods of hypotension overnight\n with a low of 77/45, pt received 1.5L of fluids\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558244, "text": "72yr M PMH: CHF EF 55%, Afib on coumadin, HTN, complete heart block w.\n pacer, insulin dependent DM, anemia, chronic kidney disease,\n degenerative disc disease, diverticulitis.\n c/o 2 days of fatigue, poor appetite, chest and L shoulder pain, worse\n with movement. syncopal episode and pts wife found him on floor unsure\n how long he had been unconscious, temp 104. taken to Hospital.\n U/S showed intra-abdominal fluid and mildly thickened gallbladder.\n He was transferred to for further management, where his vitals\n were: 97.8 100/45 70 99% 3L. He was given 2 more liters of NS and\n decadron 10mg IV X1.\n He was recently hospitalized from through for treatment\n of acute renal failure, congestive heart failure, hyponatremia, upper\n GI bleeding, and amiodarone induced thyrotoxicosis. During this\n hospitalization, he was started on theophylline for his heart failure,\n underwent cauterization for his upper GI bleeding, and was started on\n prednisone and methimazole for his amiodarone induced hyperthyroidism.\n He reports feeling well since his discharge on . However, he\n reports visiting his endocrionologist on , during which his\n theophylline and methimazole were stopped, and he reports his symptoms\n began after these medications were discontinued.\n Hypotension (not Shock)\n Assessment:\n BP range since adm 77-125/45-53, some periods of hypotension overnight\n with a low of 77/45, pt received 1.5L of fluid overnight with good BP\n response, blood and urine cultures sent results pending, received vanc\n and zosyn overnight\n Action:\n Pt has been maintaining BP with systolic >100, baseline BP 110/50, pt\n continues to report extreme thirst at times, has voided x3, refused\n foley overnight, taking Pos well\n Response:\n Maintaining adequate BP with minimal fluid resuscitation, pt fluid\n balance about net even for LOS\n Plan:\n Encourage Po intake, continue to monitor I/O, continue to monitor BP,\n provide fluid as needed, f/u culture data, continue antibiotics as\n ordered\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt reporting abd pain on admission, pt also reporting pain in the left\n upper chest at site of pacer, abd resolved following bm, pt continues\n to intermittently report pain at site of pacer, CE sent, trop flat, EKG\n AV paced, pt is receiving home doses of digoxin and amiodarone\n Action:\n Monitoring, low-sodium diet as tolerated, abd u/s to evaluate for\n ascites\n Response:\n Ascites insufficient for tapping\n Plan:\n" }, { "category": "General", "chartdate": "2129-02-04 00:00:00.000", "description": "Generic Note", "row_id": 558239, "text": "TITLE:\n Chief Complaint: Fever, leukocytosis\n 24 Hour Events:\n Overnight, pt quiet, VSS. No issues.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:57 AM\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Neurologic: No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:58 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: 71 (70 - 71) bpm\n BP: 95/53(64) {77/40(51) - 114/56(70)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,860 mL\n PO:\n TF:\n IVF:\n 1,860 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,660 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis\n Skin: Warm, spider angiomas on chest\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 141 K/uL\n 9.8 g/dL\n 208 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 101 mg/dL\n 94 mEq/L\n 127 mEq/L\n 29.0 %\n 16.9 K/uL\n [image002.jpg]\n 02:41 AM\n WBC\n 16.9\n Hct\n 29.0\n Plt\n 141\n Cr\n 3.0\n TropT\n 0.04\n Glucose\n 208\n Other labs: PT / PTT / INR:30.7/38.9/3.2, CK / CKMB /\n Troponin-T:328/9/0.04, ALT / AST:60/62, Alk Phos / T Bili:90/1.8,\n Albumin:3.4 g/dL, LDH:246 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n Assessment and Plan: 72 year old male with pmh CHF, CKD, upper GI\n bleeding w/ recent cauterization, presenting with fever and\n leukocytosis.\n .\n #Fever: Likely caused by bacterial infection given elevated white count\n and left shift. Unclear source, CXR clear, UA clear. Does have\n abdominal free fluid, which may indication of GI source. Though\n abdomen is non-tender, and CT scan does not show free air, will cover\n for GI source given recent cauterization and intrabdominal fluid.\n Given recent hospitalization will cover for MRSA and pseudomonas.\n Possibly from SBP.\n - US of abd today to assess for possibly ability to tap- will not tap\n today as INR >3\n -cont vancomycin, zosyn\n -f/u cultures\n .\n #Hypotension: Likely from sepsis, Baseline BP 110/50. Now resolved.\n - PRN fluid resuscitation, maintain MAP > 60. continue abx.\n .\n #Acute renal Failure: Likely prerenal given BUN/Cr 104/3.3, in setting\n of CHF this am down to 3.0.\n - f/u U lytes, administer fluid, hold diuretics.\n .\n #Chest Pain: Likely musculoskeletal. ekg difficult to interpret in\n setting of V-pacing but in a fib. CE o/n flat. Will continue to monitor\n clinically.\n .\n #Atrial Fibrillation: will continue with amiodarone and digoxin.\n Holding warfarin given INR >3\n -will consult endocrine and cards today re: ambiguity over being on or\n off amio.\n .\n #CHF: Mild symmetric LVH with EF 55-60%, along with moderately dilated\n RV w/ tricuspid regurgitation.\n -hold avapro, torsemide, spironolactone in setting of hypotension\n -continue digoxin.\n .\n #Transaminitis: Possibly congestive hepatopathy from right sided CHF\n and tricuspid regurgitation. will trend.\n -follow LFTs\n .\n #Thyrotoxicosis: Induced by amiodarone. Continuing amiodarone because\n benefits of controlling a-fib outweigh harms of potentiating\n thyrotoxicosis. Plan is to control symptoms with prednisone, however,\n will hold prednisone in setting of acute infection.\n -hold prednisone 20mg PO BID.\n -consulting endocrine today re: current treatment plan for\n thyrotoxicosis given need to stop prednisone in setting of infection\n .\n #Anemia:Likely from chronic kidney disease. Also in setting of\n supratherapeutic INR, it's possible intrabdominal fluid is blood. will\n continue to trend hematocrit.\n .\n #Barrett's esophogus: protonix 40mg PO BID.\n .\n #Diabetes: continue home insulin regimen\n .\n # weight loss- pt with reported 45 lb wt loss in last 12 months. ?\n etiology thyrotoxicosis. Also concerning for malignancy.\n -will review record to confirm age-appropriate cancer screening has\n been done\n .\n #) Prophylaxis: PPI, supratherapeutic INR, bowel regimen, pneumoboots.\n .\n ICU Care\n Nutrition: regular diabetic low salt diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition : Transfer to the floor today\n" }, { "category": "Nursing", "chartdate": "2129-02-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558241, "text": "Hypotension (not Shock)\n Assessment:\n BP range since adm 77-125/45-53, some periods of hypotension overnight\n with a low of 77/45, pt received 1.5L of fluids\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Radiology", "chartdate": "2129-02-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1063692, "text": " 8:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL, ? BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with apparent fall on coumadin\n REASON FOR THIS EXAMINATION:\n eval for intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:28 PM\n No intracranial hemorrhage or fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head are obtained at 5-mm section\n thickness.\n\n CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage, shift of\n normally midline structures, or evidence of acute major vascular territorial\n infarct. -white matter differentiation is preserved. Ventricular and\n sulcal size appear age appropriate. There is no fracture. Opacification of\n multiple left ethmoid air cells is noted. The mastoid air cells are well\n aerated. A 4 mm subcutaneous thin linear radiopaque density projects below the\n right orbit.\n\n IMPRESSION:\n 1. No intracranial hemorrhage or fracture.\n 2. Small metal density in the subcutaneous soft tissues below the right orbit\n of unclear etiology. Correlate with direct visual inspection.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-07 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1064373, "text": " 5:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: 72 yo male with MSSA bacteremia, evaluating for source of ba\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with MSSA bacteremia, evaluating for source.\n REASON FOR THIS EXAMINATION:\n 72 yo male with MSSA bacteremia, evaluating for source of bactermia.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf MON 7:51 PM\n No evidence of acute cholecystitis or biliary ductal dilatation. Abdominal\n ascites.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER QUADRANT ULTRASOUND\n\n INDICATION: 72-year-old man with MSSA bacteremia.\n\n COMPARISON: CT abdomen dated .\n\n FINDINGS: The liver is normal in size, echogenicity and architecture. There\n is no focal liver lesion. There is small amount of perihepatic ascites. The\n gallbladder is nondistended, the wall is thickened, which can be seen in the\n setting of ascites. No gall stones. There is no cholecystic fluid or\n gallbladder wall edema or distention to suggest acute cholecystitis. The\n common duct measures 3 mm at the porta hepatis. Hepatopetal flow is\n demonstrated in the main portal vein, biphasic nature of the waveform could be\n related to congestive heart failure.\n\n IMPRESSION:\n\n 1. No evidence of acute cholecystitis or biliary ductal dilatation.\n\n 2. Abdominal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2129-02-07 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1064374, "text": ", R. MED 11R 5:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: 72 yo male with MSSA bacteremia, evaluating for source of ba\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with MSSA bacteremia, evaluating for source.\n REASON FOR THIS EXAMINATION:\n 72 yo male with MSSA bacteremia, evaluating for source of bactermia.\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute cholecystitis or biliary ductal dilatation. Abdominal\n ascites.\n\n" }, { "category": "Radiology", "chartdate": "2129-02-04 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1063815, "text": ", MED 11:03 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ? extent of ascites- is this tapable\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with new ascites, CHF, fevers, leukocytosis. No known liver\n disease\n REASON FOR THIS EXAMINATION:\n ? extent of ascites- is this tapable\n ______________________________________________________________________________\n PFI REPORT\n PFI: Moderate ascites in all four quadrants. Paracentesis not performed due\n to elevated INR of 3.2.\n\n" }, { "category": "Radiology", "chartdate": "2129-02-05 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1063973, "text": " 7:27 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Please evaluate for a DVT\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with LUE swelling, fevers and + blood cultures\n REASON FOR THIS EXAMINATION:\n Please evaluate for a DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 8:13 AM\n No evidence of DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male with left upper extremity swelling, fevers,\n positive blood cultures. Evaluate for DVT.\n\n COMPARISON: None available in the PACS.\n\n LEFT UPPER EXTREMITY ULTRASOUND: scale, color, and pulse wave Doppler\n ultrasound of the left upper extremity were performed to evaluate for deep\n venous thrombosis. The left internal jugular vein, subclavian vein, axillary\n vein, brachial vein, basilic vein, and cephalic veins demonstrate normal color\n flow with respiratory phasicity. Responses to augmentation and Valsalva\n maneuvers are appropriate, as well as compression maneuvers.\n\n IMPRESSION: No evidence of DVT in the left upper extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-05 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1063974, "text": ", V. MED 11R 7:27 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Please evaluate for a DVT\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with LUE swelling, fevers and + blood cultures\n REASON FOR THIS EXAMINATION:\n Please evaluate for a DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-08 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 1064565, "text": " 3:51 PM\n CT UP EXT W/O C Clip # \n Reason: Does the patient have an effusion of his left shoulder and p\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with MSSA bacteremia, ARF Cr 2.2, pacemaker and new severe left\n shoulder pain, concern for septic arthritis.\n REASON FOR THIS EXAMINATION:\n Does the patient have an effusion of his left shoulder and potential evidence\n of septic arthritis radiographically?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT left shoulder.\n\n TECHNIQUE: Axial CT images of the left shoulder were obtained with selective\n sagittal and coronal reformats. No priors for comparison.\n\n HISTORY: MSSA Bacteremia, evaluate for septic arthritis.\n\n FINDINGS:\n\n There is degenerative spurring at the glenoid. In addition, there is\n degenerative cartilage loss and subchondral cyst formation at the\n acromioclavicular joint. However, there are no erosive changes identified.\n There is no gross effusion on this limited soft tissue windows of the CT.\n\n There is a focal calcific density adjacent to the greater tuberosity\n consistent with an area of calcific tendinitis.\n\n There is no fracture or dislocation identified.\n\n Small left-sided pleural effusion and subjacent dependent atelectasis is\n noted.\n\n Cardiac pacer device is identified.\n\n IMPRESSION:\n\n 1. No gross glenohumeral joint effusion or bony erosive changes to\n suggestive CT evidence of septic arthritis.\n\n 2. Degenerative changes compatible with osteoarthritis in the\n acromioclavicular and glenohumeral joints.\n\n 3. Small left-sided pleural effusion with subjacent atelectasis.\n\n\n\n\n (Over)\n\n 3:51 PM\n CT UP EXT W/O C Clip # \n Reason: Does the patient have an effusion of his left shoulder and p\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2129-02-04 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1063814, "text": " 11:03 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ? extent of ascites- is this tapable\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with new ascites, CHF, fevers, leukocytosis. No known liver\n disease\n REASON FOR THIS EXAMINATION:\n ? extent of ascites- is this tapable\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ENYa FRI 12:04 PM\n PFI: Moderate ascites in all four quadrants. Paracentesis not performed due\n to elevated INR of 3.2.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old man with new ascites, congestive heart failure, fevers,\n and leukocytosis No known liver disease. Evaluate for possible diagnostic\n paracentesis.\n\n FINDINGS: Limited abdominal ultrasound. There is moderate ascites in all four\n quadrants of the abdomen. However, the patient has significantly elevated INR\n of 3.2 in the morning of the study. Paracentesis was not performed.\n\n IMPRESSION: Moderate ascites.\n\n" }, { "category": "Radiology", "chartdate": "2129-02-09 00:00:00.000", "description": "FEE ADJUSTED IN SPECIFIC SITUATION", "row_id": 1064649, "text": " 9:53 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line in right arm, left arm swollen. Of n\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n Contrast: VISAPAQUE Amt: 10\n ********************************* CPT Codes ********************************\n * PICC W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION *\n * FLUORO GUID PLCT/REPLCT/REMOVE FEE ADJUSTED IN SPECIFIC SITUATION *\n * US GUID FOR VAS. ACCESS FEE ADJUSTED IN SPECIFIC SITUATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with pacemaker/ICD and left arm swelling. Please place PICC in\n right arm. IR guidance given concern for pacer wires.\n REASON FOR THIS EXAMINATION:\n Please place PICC line in right arm, left arm swollen. Of note, patient has\n pacer/ICD. Please be aware of pacer wires.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMPd WED 5:09 PM\n Midline placed via right basilic vein with tip in the subclavian vein. The\n line is ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 72-year-old man with left-sided pacemaker and left arm\n swelling. Request is made for PICC line placement in right arm for\n antibiotics.\n\n FELLOW: .\n\n STAFF RADIOLOGIST: who reviewed the study.\n\n SEDATION: 1% lidocaine for local anesthesia.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and\n placed supine on the imaging table. The right upper arm was prepped and\n draped in the usual sterile fashion. Access was obtained into the right\n basilic vein with ultrasound guidance using micropuncture needle. Hard-copy\n ultrasound images were obtained before and after access. A 0.018 wire was\n passed into the axillary region. It could not be advanced further into the\n SVC. As such, a 4 French angled glide catheter was advanced over the wire\n into the subclavian vein at the point of the obstruction. A venogram was\n performed which demonstrated occlusion of the subclavian vein with significant\n tortuosity and collateral vessel filling the subclavian vein. The wire could\n not be advanced through this tortuosity. At this point, the clinical team was\n notified and the joint decision was made to leave a midline in place.\n\n A 24-cm 4 French single-lumen Vaxcel catheter was advanced over the wire until\n its tip was in the subclavian vein. The wire was removed and the sheath was\n peeled away. A sterile dressing was applied after the catheter was flushed\n with saline. There were no immediate complications.\n\n IMPRESSION: Midline placed via right basilic vein with tip in the subclavian\n vein. The catheter is ready to use.\n (Over)\n\n 9:53 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line in right arm, left arm swollen. Of n\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n Contrast: VISAPAQUE Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-09 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1064650, "text": ", R. MED 11R 9:53 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line in right arm, left arm swollen. Of n\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n Contrast: VISAPAQUE Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with pacemaker/ICD and left arm swelling. Please place PICC in\n right arm. IR guidance given concern for pacer wires.\n REASON FOR THIS EXAMINATION:\n Please place PICC line in right arm, left arm swollen. Of note, patient has\n pacer/ICD. Please be aware of pacer wires.\n ______________________________________________________________________________\n PFI REPORT\n Midline placed via right basilic vein with tip in the subclavian vein. The\n line is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-18 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1066440, "text": " 2:23 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: spoke with , patient needing tunnelled double-lumen d\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ARF, right heart failure with coagulaopathy being\n agressively reversed.\n REASON FOR THIS EXAMINATION:\n spoke with , patient needing tunnelled double-lumen dialysis catheter.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBCa FRI 7:14 PM\n Uncomplicated tunneled hemodialysis catheter through the right internal\n jugular venous approach,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with acute renal failure.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist, who was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiography table and the right neck and chest were prepped and\n draped in standard sterile fashion. A preprocedure timeout was performed.\n\n Using sterile technique, local anesthesia and direct ultrasound guidance, the\n right internal jugular vein was punctured and a 0.018 guidewire was advanced\n through the needle into the SVC under fluoroscopic guidance. The needle was\n then exchanged over the wire for a micropuncture sheath. The wire and the\n inner dilator of the sheath were removed and a 0.035 wire was advanced\n through the sheath into the IVC under fluoroscopic guidance.\n\n Attention was now directed to the construction of the subcutaneous tunnel.\n After using approximately 10 mL of 1% lidocaine with epinephrine, a\n subcutaneous tunnel was created with a blunt tunneling device. The catheter\n was advanced through the tunnel and through the puncture site at the neck.\n The puncture site was progressively dilated with 12 and 14 French dilators. A\n 14.5 French peel-away sheath was advanced over the wire into the right atrium\n under fluoroscopic guidance. The wire and the inner dilator of the sheath\n were removed and the catheter was advanced through the peel-away sheath into\n the right atrium. The peel-away sheath was removed.\n\n The catheter was flushed, heplocked and capped. The catheter was secured to\n the skin with 0 silk suture and the skin entry site in the neck was closed\n with 2-0 Vicryl suture. A sterile dressing was applied.\n\n Final fluoroscopic image of the chest demonstrates the tip of the catheter to\n be located within the right atrium.\n\n (Over)\n\n 2:23 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: spoke with , patient needing tunnelled double-lumen d\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The patient tolerated the procedure well without immediate complications.\n Moderate sedation was provided by administering divided doses of 75 mcg of\n fentanyl and 2 mg of Versed throughout the total intraservice time of 25\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n IMPRESSION: Uncomplicated placement of a tunneled hemodialysis catheter\n through the right internal jugular venous approach. The catheter is ready for\n use.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-18 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1066441, "text": ", R. MED 11R 2:23 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: spoke with , patient needing tunnelled double-lumen d\n Admitting Diagnosis: FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ARF, right heart failure with coagulaopathy being\n agressively reversed.\n REASON FOR THIS EXAMINATION:\n spoke with , patient needing tunnelled double-lumen dialysis catheter.\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated tunneled hemodialysis catheter through the right internal\n jugular venous approach,\n\n" }, { "category": "Radiology", "chartdate": "2129-02-03 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1063685, "text": " 6:34 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for acute intrabdominal catastrophe\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with swollen belly, sp procedure, with positive fast exam and\n hypotensive\n REASON FOR THIS EXAMINATION:\n eval for acute intrabdominal catastrophe\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 7:10 PM\n Moderate free fluid in the abdomen and pelvis, though does not appear\n completely simple base on attenuation values. No definite source. Metallic\n density in stomach near GE junction may related to recent endoscopy and\n cauterization.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with swollen abdomen status post endoscopy with\n positive FAST exam.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the abdomen and pelvis are obtained\n with multiplanar reformatted images. IV Contrast was not administered due to\n renal failure. Mo oral; contrast was administered.\n\n CT ABDOMEN WITHOUT CONTRAST: Small right greater than left pleural effusions\n are associated with bibasilar atelectasis. The patient is status post median\n sternotomy with cardiomegaly and biventricular pacemaker leads partially\n imaged. Note is made of gynecomastia bilaterally.\n\n Non-contrast evaluation of abdominal organs including the liver, gallbladder,\n spleen, pancreas, adrenal glands, and kidneys are unremarkable. There is no\n hydronephrosis or hydroureter. Intra-abdominal loops of large and small bowel\n are of normal caliber and there is no pneumoperitoneum. A small metallic\n density, approximately 1 cm in size, within the proximal stomach near the\n gastroesophageal junction is of unknown etiology. A moderate amount of ascites\n is noted, with attenuation values mostly suggesting simple fluid. Scattered\n mesenteric and retroperitoneal lymph nodes measure up to 10 mm in short axis.\n Atherosclerotic calcifications involve the abdominal aorta though it is of\n normal caliber. A small fat containing ventral hernia is inferior to the\n sternum (2:25).\n\n CT PELVIS WITHOUT CONTRAST: The rectum, sigmoid colon and bladder are\n unremarkable. There is moderate free pelvic fluid. There are no\n pathologically enlarged pelvic or inguinal lymph nodes.\n\n Bone windows reveal no worrisome lytic or sclerotic lesions. Remote pubic rami\n fractures are healed. There is multilevel mild to moderate thoracolumbar\n spondylosis and facet arthropathy.\n (Over)\n\n 6:34 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for acute intrabdominal catastrophe\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Moderate ascites of unclear etiology, though liver disease should be\n considered in the setting of gynecomastia.\n 2. Small bilateral pleural effusions and atelectasis.\n 3. Small metallic density in the proximal stomach is of unknown\n etiology. Correlation is needed.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-03 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1063686, "text": " 6:35 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: eval for acute cardiothoracic process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with positive fast exam and fever\n REASON FOR THIS EXAMINATION:\n eval for acute cardiothoracic process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with fever and abdominal distention.\n\n COMPARISON: CXR, .\n\n AP SUPINE CHEST: An ICD remains in place with two right ventricular leads and\n one right atrial lead. An additional lead is again noted for biventricular\n pacing. The patient is status post median sternotomy with unchanged appearance\n of the cardiomediastinal silhouette. The pulmonary vascularity is stable.\n There is no focal lung consolidation, pleural effusion, or pneumothorax.\n\n IMPRESSION: Cardiomegaly without focal lung consolidation or overt edema.\n\n" }, { "category": "ECG", "chartdate": "2129-02-04 00:00:00.000", "description": "Report", "row_id": 241384, "text": "Atrial and ventricular sequential pacing. Compared to the previous tracing\nthere is no significant change.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2158-08-28 00:00:00.000", "description": "Report", "row_id": 127499, "text": "Sinus rhythm. There are Q waves in the inferior leads consistent with prior\nmyocardial infarction. There is a late transition that is probably normal.\nInferior and anterolateral ST-T wave changes consistent with a recent\ninferior myocardial infarction. Compared to the previous tracing there is no\nsignificant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 127500, "text": "Sinus rhythm. There are Q waves in the inferior leads consistent with prior\nmyocardial infarction. There is a late transition that is probably normal.\nST-T wave changes in the inferior and anterolateral leads consistent with a\nrecent myocardial infarction. Compared to the previous tracing inferior\nST segment elevation is resolved.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 127501, "text": "Sinus rhythm. ST segment elevation in the inferior leads with terminal T wave\ninversion and reciprocal ST segment depression elsewhere consistent with acute\nevolving myocardial infarction. Compared to the previous tracing the magnitude\nof ST segment elevation is less.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 127502, "text": "Sinus rhythm. Non-specific intraventricular conduction delay. There is\nST segment elevation in the inferior leads with reciprocal ST segment\ndepression in the other leads consistent with acute evolving myocardial\ninfarction. The Q-T interval is prolonged. Compared to the previous tracing\ninferior acute ST segment elevation myocardial infarction is new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388554, "text": "61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection of atrial myxoma\n in (with one vessel bypass at this time) who awoke the morning\n of at ~4AM with crushing chest pain. She was brought to the\n ED where EKG showed ST elevations in inferior leads. A code STEMI\n was activated and the pt was brought to the cath lab where she was\n found to have an occlusion of her RCA. Prior to the intervention she\n received integrilin, heparin, , , and nitroglycerin. SBP >\n 100 in L arm. R arm noted to be much lower per report by art line BP\n higher in cath lab. Post procedure Pt denies chest pain. s/p DES to\n RCA with Angioseal to R groin c/b hematoma. Integrilin dc\nd in lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n NO CP, SOB .SR OCC PAC,BP 100 TO 110 SYSTOLIC.TOL CORREG,LISINOPRIL\n .SOFT HEMATOMA R GROIN CATH SITE ,DISTAL PULSES BY DOPPLER .SAT 100 RM\n AIR.20MG IV LASIX GIVEN FOR CRACKLES IN BASES.FOLEY ,VOIDED 400 CC\n GOOD APPETITE NO STOOL,COLACE GIVEN ,AM HCT STABLE,MG REPLETED\n Action:\n PT OOB,CARDIAC MEDS, LASIX GIVEN ,MI TEACHING\n Response:\n TOL INCREASE ACTIVITY , HR 67 P AM CORREG, TOL MEDS ,HAS UNDERSTANDING\n OF DX\n Plan:\n ADVANCE ACTIVITY ,CONTINUE TEACHING,MONITOR RESPONSE TO MEDS,FOLLOW\n FLUID BALANCE ,LYTES,HCT,ANY BLEEDING FROM R GROIN\n Diabetes Mellitus (DM), Type I\n Assessment:\n BS ELEVATED\n Action:\n NPH,HUMULOG INSULIN PER SCALE\n Response:\n BS 176 to 200S\n Plan:\n CLOSE BS MONITORING\n" }, { "category": "Physician ", "chartdate": "2158-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388543, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CHEST PAIN - At 08:00 PM\n pt c/o CP 12 lead done team eval pt morphine 2 mg IVP\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:15 PM\n Heparin Sodium (Prophylaxis) - 11:00 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 09:29 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: 36.1\nC (97\n HR: 74 (74 - 102) bpm\n BP: 98/55(66) {96/51(62) - 122/75(85)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.9 kg (admission): 71 kg\n Total In:\n 1,720 mL\n PO:\n 250 mL\n TF:\n IVF:\n 1,470 mL\n Blood products:\n Total out:\n 2,300 mL\n 480 mL\n Urine:\n 650 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -580 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.9 g/dL\n 228 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 139 mEq/L\n 33.3 %\n 14.5 K/uL\n [image002.jpg]\n 04:32 PM\n 11:31 PM\n 05:04 AM\n WBC\n 8.7\n 11.8\n 14.5\n Hct\n 36.0\n 34.3\n 33.3\n Plt\n \n Cr\n 1.0\n 1.0\n 0.9\n TropT\n 1.04\n 0.65\n Glucose\n 397\n 354\n 228\n Other labs: PT / PTT / INR:12.0/26.6/1.0, CK / CKMB /\n Troponin-T:288/41/0.65, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n DIABETES MELLITUS (DM), TYPE I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388547, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388549, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388537, "text": "61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection of atrial myxoma\n in (with one vessel bypass at this time) who awoke the morning\n of at ~4AM with crushing chest pain. She was brought to the\n ED where EKG showed ST elevations in inferior leads. A code STEMI\n was activated and the pt was brought to the cath lab where she was\n found to have an occlusion of her RCA. Prior to the intervention she\n received integrilin, heparin, , , and nitroglycerin. SBP >\n 100 in L arm. R arm noted to be much lower per report by art line BP\n higher in cath lab. Post procedure Pt denies chest pain. s/p DES to\n RCA with Angioseal to R groin c/b hematoma. Integrilin dc\nd in lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n At start of shift pt C/o chest discomfort off/ on out of ten, did\n not improve with sitting up no worse with deep breath . Pt denies SOB,\n received one liter D51/2ns with bicarb post procedure hydration.\n Action:\n 12 Lead done reviewed by team, no new changes. pt given 2 mg morphine\n with complete relief and Tylenol 650 as well. Pt had one 6 beat run VT\n rate 134, overnight house staff aware, CPK peak 500 now 356- no\n further arrhythmias, carvedolol dose increased but lisinopril held as\n ? of bleeding, though HCT dropped to 36, was 34.5 at midnight check.\n Response:\n Hemo dynamically stable, no further arrhythmias, K 4.0 at midnight\n tolerated hydration. Right groin hematoma soft and stable distal pulses\n weak palp and confirmed by doppler\n Plan:\n Check hct this Am, cont to assess groin. Titrate cardiac meds as BP\n tolerates.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt takes NPH and RISSC. Pt did not take am insulin yesterday . Bld\n sugars in 300\ns. was hydrating with IV D5\n NS with bicarb at 75cc/hr\n x\ns 1200cc.\n Action:\n 11pm glucose 404 rec 12 unit regular and 10 NPH hydration with dextrose\n IVF dc\nd at that time. Later FS 220\n Response:\n Pt to get her regular dose insulin in morning with breakfast\n Plan:\n Continue home regime follow glucose\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388550, "text": "61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection of atrial myxoma\n in (with one vessel bypass at this time) who awoke the morning\n of at ~4AM with crushing chest pain. She was brought to the\n ED where EKG showed ST elevations in inferior leads. A code STEMI\n was activated and the pt was brought to the cath lab where she was\n found to have an occlusion of her RCA. Prior to the intervention she\n received integrilin, heparin, , , and nitroglycerin. SBP >\n 100 in L arm. R arm noted to be much lower per report by art line BP\n higher in cath lab. Post procedure Pt denies chest pain. s/p DES to\n RCA with Angioseal to R groin c/b hematoma. Integrilin dc\nd in lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n NO CP, SOB .SR OCC PAC,BP 100 TO 110 SYSTOLIC.TOL CORREG,LISINOPRIL\n .SOFT HEMATOMA R GROIN CATH SITE ,DISTAL PULSES BY DOPPLER .SAT 100 RM\n AIR.20MG IV LASIX GIVEN FOR CRACKLES IN BASES.FOLEY DC 1030 AM DTV\n 630 PM. GOOD APPETITE NO STOOL,COLACE GIVEN ,AM HCT STABLE,MG REPLETED\n Action:\n PT OOB,CARDIAC MEDS, LASIX GIVEN ,MI TEACHING\n Response:\n TOL INCREASE ACTIVITY , HR 67 P AM CORREG, TOL MEDS ,HAS UNDERSTANDING\n OF DX\n Plan:\n ADVANCE ACTIVITY ,CONTINUE TEACHING,MONITOR RESPONSE TO MEDS,FOLLOW\n FLUID BALANCE ,LYTES,HCT,ANY BLEEDING FROM R GROIN\n Diabetes Mellitus (DM), Type I\n Assessment:\n BS ELEVATED\n Action:\n NPH,REGULAR INSULIN PER SCALE\n Response:\n BS 200S\n Plan:\n CLOSE BS MONITORING\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388517, "text": "61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection of atrial myxoma\n in (with one vessel bypass at this time) who awoke the morning\n of at ~4AM with crushing chest pain. She was brought to the\n ED where EKG showed ST elevations in inferior leads. A code STEMI\n was activated and the pt was brought to the cath lab where she was\n found to have an occlusion of her RCA. Prior to the intervention she\n received integrilin, heparin, , , and nitroglycerin. SBP >\n 100 in L arm. R arm noted to be much lower per report by art line BP\n higher in cath lab. Post procedure Pt denies chest pain. s/p DES to\n RCA with Angioseal to R groin c/b hematoma. Integrilin dc\nd in lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n At start of shift pt C/o chest discomfort off/ on out of ten, did\n not improve with sitting up no worse withdeep breath . Pt denies SOB\n received one liter D51/2ns with bicrb post procedure hydration.\n Action:\n 12 Lead done rreviewed by team no new changes pt given 2 mg morphine\n with complete relief and Tylenol 650 as well. Pt had one 6 beat run VT\n rate 134, overnight house staff aware, cpk max 550 now 350- no further\n arrythmias, carvedolo increased but lisinopril held as ? of blleding,\n though HCT dropped 35 at midnight check\n Response:\n Hemo dynamically stable, no further arrythmias, K 4.0 at midnight\n tolerated hydration. Right hematoma soft and stable distal pulses\n weak palp and confirmend by doppler\n Plan:\n Check hct thisin Am, cont to assess groin. Titrate cardiac meds as BP\n tolerates.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt takes NPH and RISSC. Pt did not take am insulin. Bld sugars in\n 300\ns. IV D5\n NS with bicarb at 75cc/hr x\ns 1200cc.\n Action:\n AM dose given with RISS\n Response:\n Bld sugars remain ^\nd ? d/t IV fluid post cath. House staff aware.\n Given 1 time extra dose of humalog.I\n Plan:\n Insulin per home regime with RISSC.\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388518, "text": "61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection of atrial myxoma\n in (with one vessel bypass at this time) who awoke the morning\n of at ~4AM with crushing chest pain. She was brought to the\n ED where EKG showed ST elevations in inferior leads. A code STEMI\n was activated and the pt was brought to the cath lab where she was\n found to have an occlusion of her RCA. Prior to the intervention she\n received integrilin, heparin, , , and nitroglycerin. SBP >\n 100 in L arm. R arm noted to be much lower per report by art line BP\n higher in cath lab. Post procedure Pt denies chest pain. s/p DES to\n RCA with Angioseal to R groin c/b hematoma. Integrilin dc\nd in lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n At start of shift pt C/o chest discomfort off/ on out of ten, did\n not improve with sitting up no worse with deep breath . Pt denies SOB,\n received one liter D51/2ns with bicarb post procedure hydration.\n Action:\n 12 Lead done reviewed by team, no new changes. pt given 2 mg morphine\n with complete relief and Tylenol 650 as well. Pt had one 6 beat run VT\n rate 134, overnight house staff aware, CPK peak 500 now 356- no\n further arrhythmias, carvedolol dose increased but lisinopril held as\n ? of bleeding, though HCT dropped to 36, was 34.5 at midnight check.\n Response:\n Hemo dynamically stable, no further arrhythmias, K 4.0 at midnight\n tolerated hydration. Right groin hematoma soft and stable distal pulses\n weak palp and confirmed by doppler\n Plan:\n Check hct this Am, cont to assess groin. Titrate cardiac meds as BP\n tolerates.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt takes NPH and RISSC. Pt did not take am insulin yesterday . Bld\n sugars in 300\ns. was hydrating with IV D5\n NS with bicarb at 75cc/hr\n x\ns 1200cc.\n Action:\n 11pm glucose 404 rec 12 unit regular and 10 NPH hydration with dextrose\n dc\nd at that time.\n Response:\n .I\n Plan:\n" }, { "category": "General", "chartdate": "2158-08-27 00:00:00.000", "description": "Generic Note", "row_id": 388481, "text": "TITLE:\n CCU Intern Event Note:\n Post cath check:\n S: Venous sheath pulled approximately 11 AM this morning. At time of\n post-cath check patient has no complaints. She denies chest pain,\n shortness of breath, groin pain, back pain.\n O: T 98.7 HR 91 BP 110/68 RR 15 O2 Sat 98%\n Gen: AOX3, NAD\n HEENT: normocephalic, oropharynx clear\n Resp: CTAB\n Cards: nml s1, s2, no m/r/g\n Abd: soft, nt/nd, +BS\n Ext: WWP no c/c/e. R groin catheter site clean, dry, intact. Small\n palpable hematoma, not expanded from line marking border earlier in the\n day. No audible bruits.\n Pulses: DP/PT pulses faint, 1+ bilaterally\n Neuro: CN II-XII intact\n Labs:\n Post cath Hct 36.0 (Previous 41.6)\n A/P:\n 61 yo F s/p cardiac catheterization for STEMI with DES placed to RCA\n - Post cath check completed\n - Pt hemodynamically stable with no evidence of expanding hematoma,\n retroperitoneal bleed, cholesterol emboli, or pseudoaneurysm\n - Will recheck Hematocrit at 12AM, order T+S as preventative measure in\n case Pt becomes hemodynamically unstable or has notable Hct drop\n - Continuing current management with ASA, plavix, lisinopril, statin,\n carvedilol\n" }, { "category": "Nursing", "chartdate": "2158-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388488, "text": "Briefly this is a 61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection\n of atrial myxoma in (with one vessel bypass at this time) who\n awoke the morning of at ~4AM with crushing chest pain. She was\n brought to the ED where EKG showed ST elevations in inferior\n leads. A code STEMI was activated and the pt was brought to the cath\n lab where she was found to have an occlusion of her RCA. Prior to the\n intervention she received integrilin, heparin, , , and\n nitroglycerin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm 90\ns SBP > 100 in L arm. R arm noted to be much\n lower. Pt denies chest pain. s/p DES to RCA with Angioseal to R groin\n c/b hematoma. Distal pulses are faint.\n Action:\n Integrilin dc\nd in lab. Pt restarted on cardiac meds. Carvedlol dose\n ^\nd. Lisinopril held d/t concern regarding bleeding. Hematoma is\n unchanged . slight hct drop.\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt takes NPH and RISSC. Pt did not take am insulin. Bld sugars in\n 300\ns. IV D5\n NS with bicarb at 75cc/hr x\ns 1200cc.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388491, "text": "Briefly this is a 61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection\n of atrial myxoma in (with one vessel bypass at this time) who\n awoke the morning of at ~4AM with crushing chest pain. She was\n brought to the ED where EKG showed ST elevations in inferior\n leads. A code STEMI was activated and the pt was brought to the cath\n lab where she was found to have an occlusion of her RCA. Prior to the\n intervention she received integrilin, heparin, , , and\n nitroglycerin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm 90\ns SBP > 100 in L arm. R arm noted to be much\n lower. Pt denies chest pain. s/p DES to RCA with Angioseal to R groin\n c/b hematoma. Distal pulses are faint.\n Action:\n Integrilin dc\nd in lab. Pt restarted on cardiac meds. Carvedlol dose\n ^\nd. Lisinopril held d/t concern regarding bleeding. Hematoma is\n unchanged . slight hct drop.\n Response:\n Hemo dynamically stable.\n Plan:\n Check hct this pm, cont to assess groin. Titrate cardiac meds as BP\n tolerates.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt takes NPH and RISSC. Pt did not take am insulin. Bld sugars in\n 300\ns. IV D5\n NS with bicarb at 75cc/hr x\ns 1200cc.\n Action:\n AM dose given with RISS\n Response:\n Bld sugars remain ^\nd ? d/t IV fluid post cath. House staff aware.\n Given 1 time extra dose of humalog.I\n Plan:\n Insulin per home regime with RISSC.\n" }, { "category": "Nursing", "chartdate": "2158-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388478, "text": "Briefly this is a 61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection\n of atrial myxoma in (with one vessel bypass at this time) who\n awoke the morning of at ~4AM with crushing chest pain. She was\n brought to the ED where EKG showed ST elevations in inferior\n leads. A code STEMI was activated and the pt was brought to the cath\n lab where she was found to have an occlusion of her RCA. Prior to the\n intervention she received integrilin, heparin, , , and\n nitroglycerin.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2158-08-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388460, "text": "Chief Complaint: chest pain\n HPI:\n 61 year old African-American female with a h/o CAD\n s/p MI, s/p 1v CABG , cholelithiasis, GERD, hypertension,\n type 2 diabetes mellitus who was in her usual state of health until 4am\n today. She suddenly woke up with diffuse chest pressure, shortness of\n breath, nausea, vomiting, and diaphoresis. She says this pain is\n different from the pain that she had with her previous MI. That was\n more L sided sharp pain, where as this was more diffuse pressure.\n .\n Her husband immediately brought her to the emergency department.\n At 6:50am her vitals were T 97.2 HR 99 BP 119/71 RR 16 96% on RA.\n EKG showed ST elevations in leads II, III, aVF with ST depressions in\n V2-V6. A Code STEMI was called. She received full dose ASA, oxygen,\n plavix load, heparin bolus, integrellin, morphine, and was started on a\n nitro gtt.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of paroxysmal\n nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or\n presyncope.\n .\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Aspirin 81 mg po daily\n 2. Carvedilol 3.125 mg po bid\n 3. Lisinopril 2.5 mg po daily\n 4. Pantoprazole 40 mg po daily\n 5. Thiamine 100 mg po daily\n 6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl\n Topical PRN itching.\n 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:\n 15-30 MLs PO QID (4 times a day) PRN chest pain.\n 8. Insulin Regular Human 100 unit/mL Solution Sig: Twenty Four\n (24) units Injection BREAKFAST (Breakfast).\n 9. NPH 32 units qAM, 10 units qPM.\n 10. Furosemide 10 mg po daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG: 1 vessel Saphenous vein graft to diagonal artery.\n \n -PERCUTANEOUS CORONARY INTERVENTIONS: See below\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n h/o atrial myxoma s/p surgical removal \n GERD.\n Chest pain syndrome\n History of stroke with residual mild left-sided\n hemiparesis and left facial tingling.\n History of left breast cyst, status post excision which\n was benign.\n Status post hysterectomy and unilateral oophorectomy.\n Statin-induced pancreatitis ()\n Carpal Tunnel\n Mother with DM, CAD (deceased)\n 3 brothers with DM\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives with husband, occasional tobacco use, no ETOH, no illicits\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n VS: BP=118/73 HR=95 RR=22 O2 sat= 98%\n GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No murmurs. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No LE edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n [image002.jpg]\n Imaging: \n .\n The left atrium and right atrium are normal in cavity size. No left\n atrial mass/thrombus seen (best excluded by transesophageal\n echocardiography). Left ventricular wall thicknesses and cavity size\n are normal. Regional left ventricular wall motion is normal. Overall\n left ventricular systolic function is low normal (LVEF 50-55%). Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n structurally normal. There is no mitral valve prolapse. Mild (1+)\n mitral regurgitation is seen. There is borderline pulmonary artery\n systolic hypertension.\n Compared with the prior study (images reviewed) of , regional\n left ventricular systolic function is improved. No residual myxoma\n identified. The severity of mitral regurgitation is similar.\n C. Cath \n LAD: 40% mid, 60% diagonal origin\n LCx: 60% inferior branch of OM1\n RCA: long 90% mid with thrombus, 40% distally\n SVG: diagonal patent\n -thrombectomy of mid RCA and DES of mid RCA placed\n .\n CXR (my read): Cardiomegaly. Diaphragms well visualized. No\n effusions. Patchy infiltrates at bases -atelectasis vs. congestion,\n seen on prior CXR from .\n ECG: EKG: 9am\n NSR @ 93bpm. TWI in V4-V6, III and aVF. ST elevations in III and aVF.\n Lateral lead ST depressions.\n Assessment and Plan\n 61 yo F with history of DM2, CAD s/p 1v CABG, and HTN who presented to\n ED with STEMI this morning, s/p cath and DES placed to RCA.\n .\n # CORONARIES: Known CAD s/p 1v CABG. s/p c. cath this AM with DES\n placed to RCA.\n -full dose ASA\n -plavix 75mg po daily x1 year\n -lisinopril 2.5mg po daily\n -carvedilol 3.125mg po daily -titrate up to HR in 60s\n -post cath check this afternoon\n .\n # PUMP: EF 50-55%. Patient takes 10mg po lasix for ankle edema, but\n denies orthopnea or PND. Currently appears euvolemic.\n -hold lasix for now. Would monitor I/Os with goal of keeping her net\n even\n .\n # RHYTHM: Currently NSR\n -monitor on telemetry\n .\n # Leukocytosis: WBC 14.4. Likely from STEMI. If patient develops\n fevers or develops worsening leukocytosis, would send blood cultures,\n UA, sputum cultures.\n .\n # DM2: Continue NPH 32 units in AM, 10 units in PM, per outpatient\n regimen.\n -SSI\n -qid fingersticks\n -diabetic diet\n .\n # GERD: Patient mentions that she has fairly severe GERD. Will hold\n Pantoprazole given that she is on plavix, and try ranitidine while in\n house.\n .\n .\n FEN: Heart healthy, diabetic diet. No IV fluids. Replete electrolytes\n PRN.\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SQ\n -Pain management with tylenol PRN\n -Bowel regimen with colace PRN\n .\n CODE: FULL -confirmed with patient\n .\n COMM: husband\n .\n DISPO: CCU for now\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2158-08-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388461, "text": "Chief Complaint: chest pain\n HPI:\n 61 year old African-American female with a h/o CAD\n s/p MI, s/p 1v CABG , cholelithiasis, GERD, hypertension,\n type 2 diabetes mellitus who was in her usual state of health until 4am\n today. She suddenly woke up with diffuse chest pressure, shortness of\n breath, nausea, vomiting, and diaphoresis. She says this pain is\n different from the pain that she had with her previous MI. That was\n more L sided sharp pain, where as this was more diffuse pressure.\n .\n Her husband immediately brought her to the emergency department.\n At 6:50am her vitals were T 97.2 HR 99 BP 119/71 RR 16 96% on RA.\n EKG showed ST elevations in leads II, III, aVF with ST depressions in\n V2-V6. A Code STEMI was called. She received full dose ASA, oxygen,\n plavix load, heparin bolus, integrellin, morphine, and was started on a\n nitro gtt.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of paroxysmal\n nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or\n presyncope.\n .\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Aspirin 81 mg po daily\n 2. Carvedilol 3.125 mg po bid\n 3. Lisinopril 2.5 mg po daily\n 4. Pantoprazole 40 mg po daily\n 5. Thiamine 100 mg po daily\n 6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl\n Topical PRN itching.\n 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:\n 15-30 MLs PO QID (4 times a day) PRN chest pain.\n 8. Insulin Regular Human 100 unit/mL Solution Sig: Twenty Four\n (24) units Injection BREAKFAST (Breakfast).\n 9. NPH 32 units qAM, 10 units qPM.\n 10. Furosemide 10 mg po daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG: 1 vessel Saphenous vein graft to diagonal artery.\n \n -PERCUTANEOUS CORONARY INTERVENTIONS: See below\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n h/o atrial myxoma s/p surgical removal \n GERD.\n Chest pain syndrome\n History of stroke with residual mild left-sided\n hemiparesis and left facial tingling.\n History of left breast cyst, status post excision which\n was benign.\n Status post hysterectomy and unilateral oophorectomy.\n Statin-induced pancreatitis ()\n Carpal Tunnel\n Mother with DM, CAD (deceased)\n 3 brothers with DM\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives with husband, occasional tobacco use, no ETOH, no illicits\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n VS: BP=118/73 HR=95 RR=22 O2 sat= 98%\n GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No murmurs. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No LE edema. R groin, catheter still\n in place. 3x3cm hematoma. Not tender to palpation. No bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n [image002.jpg]\n Imaging: \n .\n The left atrium and right atrium are normal in cavity size. No left\n atrial mass/thrombus seen (best excluded by transesophageal\n echocardiography). Left ventricular wall thicknesses and cavity size\n are normal. Regional left ventricular wall motion is normal. Overall\n left ventricular systolic function is low normal (LVEF 50-55%). Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n structurally normal. There is no mitral valve prolapse. Mild (1+)\n mitral regurgitation is seen. There is borderline pulmonary artery\n systolic hypertension.\n Compared with the prior study (images reviewed) of , regional\n left ventricular systolic function is improved. No residual myxoma\n identified. The severity of mitral regurgitation is similar.\n C. Cath \n LAD: 40% mid, 60% diagonal origin\n LCx: 60% inferior branch of OM1\n RCA: long 90% mid with thrombus, 40% distally\n SVG: diagonal patent\n -thrombectomy of mid RCA and DES of mid RCA placed\n .\n CXR (my read): Cardiomegaly. Diaphragms well visualized. No\n effusions. Patchy infiltrates at bases -atelectasis vs. congestion,\n seen on prior CXR from .\n ECG: EKG: 9am\n NSR @ 93bpm. TWI in V4-V6, III and aVF. ST elevations in III and aVF.\n Lateral lead ST depressions.\n Assessment and Plan\n 61 yo F with history of DM2, CAD s/p 1v CABG, and HTN who presented to\n ED with STEMI this morning, s/p cath and DES placed to RCA.\n .\n # CORONARIES: Known CAD s/p 1v CABG. s/p c. cath this AM with DES\n placed to RCA.\n -full dose ASA\n -plavix 75mg po daily x1 year\n -lisinopril 2.5mg po daily\n -carvedilol 3.125mg po daily -titrate up to HR in 60s\n -post cath check 4-6 hours after removal of catheter\n .\n # PUMP: EF 50-55%. Patient takes 10mg po lasix for ankle edema, but\n denies orthopnea or PND. Currently appears euvolemic.\n -hold lasix for now. Would monitor I/Os with goal of keeping her net\n even\n .\n # RHYTHM: Currently NSR\n -monitor on telemetry\n .\n # Leukocytosis: WBC 14.4. Likely from STEMI. If patient develops\n fevers or develops worsening leukocytosis, would send blood cultures,\n UA, sputum cultures.\n .\n # DM2: Continue NPH 32 units in AM, 10 units in PM, per outpatient\n regimen.\n -SSI\n -qid fingersticks\n -diabetic diet\n .\n # GERD: Patient mentions that she has fairly severe GERD. Will hold\n Pantoprazole given that she is on plavix, and try ranitidine while in\n house.\n .\n .\n FEN: Heart healthy, diabetic diet. No IV fluids. Replete electrolytes\n PRN.\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SQ\n -Pain management with tylenol PRN\n -Bowel regimen with colace PRN\n .\n CODE: FULL -confirmed with patient\n .\n COMM: husband\n .\n DISPO: CCU for now\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2158-08-27 00:00:00.000", "description": "Cardiology Teaching Physician Note", "row_id": 388467, "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 Above discussed extensively with patient.\n Total time spent on patient care: 35 minutes of critical care time.\n Additional comments:\n Critically ill due to acute inferior ST elevation MI, acute diastolic\n CHF, Hematoma.\n Date/time of service was 9.27.9 at 12:30.\n" }, { "category": "Physician ", "chartdate": "2158-08-27 00:00:00.000", "description": "Cardiology Fellow Admission Note", "row_id": 388468, "text": "History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: Please see resident H and P for\n full history and physical exam\n Briefly this is a 61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection\n of atrial myxoma in (with one vessel bypass at this time) who\n awaoke the morning of at ~4AM with crushing chest pain. She was\n brought to the ED where EKG showed ST elevations in inferior\n leads. A code STEMI was activated and the pt was brought to the cath\n lab where she was found to have an occlusion of her RCA. Prior to the\n intervention she recieved integrilin, heparin, , , and\n nitrglycerine.\n PMHx:\n 1. DM\n 2. HL\n 3. HTN\n 4. GERD\n 5. resection of atrial myxoma in w/ 1 vessel CABG at time of\n surgery\n stroke w/ residual L sided hemiparesis and L facial tingling\n 6. pancreatitis - statin induced\n Medications\n Home:\n 81mg daily\n Coreg 3.125mg \n Lisinopril 2.5mg daily\n Pantoprazole 40mg daily\n Thiamine 100mg daily\n Triamcinolone Acetonide\n Insulin - NPH 32 Units qAM and 10 Units qPM\n Furosemide 10mg daily\n Physical Exam\n Gen: Alert and orientated x3, NAD\n HEENT: PERRLA, EMOI, mucosa moist\n Neck: no thyromegaly, no JVD, no carotid bruits\n CV: RRR no MRG, PMI non-displaced, normal s1 and s2\n Pulm: CTAB no RRW\n Abd: soft, NT/ ND, bs+, no HSM, no CVA tenderness\n Groin: sheaths pulled and dressing over right groin c/d/i. Hematoma\n present in right groin which extends medially and superior to venous\n access site. No bruits heard over femoral arteries bilaterally.\n Ext: no c/c/e, DP and PT pulses palpable bilaterally and unchanged from\n prior to catheterization\n Neuro: CN II-XII grossly intact\n BP: 111 / 66 mmHg\n HR: 93 bpm\n RR: 20 insp/min\n O2 sat: 98 % on Room air\n Previous day:\n Output: 0 mL\n Fluid balance: 0 mL\n Today:\n Output: 0 mL\n Fluid balance: 0 mL\n Labs\n Outside / other labs: CE: CK 61, Trop < 0.01\n CBC: WBC 14.4, Hgb 13.2 w/ MCV of 78, plt 225\n Chem7: grossly normal save for glc of 318 (Cr is 1 w/ BUN of 9)\n Tests\n ECG: (Date: ), Sinus w/ ST elevations in inferior leads (III>II)\n with reciprocal changes.\n Echocardiogram: (Date: ), EF 50%, The left atrium and right\n atrium are normal in size. No left atrial mass/thrombus seen. Left\n ventricular wall thicknesses and cavity size are normal. Regional left\n ventricular wall motion is normal. Right ventricular chamber size and\n free wall motion are normal. Mild (1+) mitral regurgitation is seen.\n There is borderline pulmonary artery systolic hypertension\n Cardiac Cath: (Date: ), LAD: 40% mid and 60% at origin of D1\n Cx: 60% in the inferior branch of OM1\n RCA: long 90% mid stenosis with thrombus present. 40% in the distal\n vessel.\n SVG: patent to D1\n now s/p DES to RCA.\n Assessment and Plan\n 61 yo F w/ PMHx of HTN, HL, DM, s/p atrial myxoma resection w/ 1v CABG\n to D1 in admitted with a STEMI and now s/p cathwith PCI to RCA\n (DES).\n 1. CAD s/p STEMI\n -\n -\n -continue lisinopril and coreg\n -due to high arterial puncture site will d/c integrilin as per Dr.\n \n 2. Hematoma/ Groin access\n -non expanding hematoma when venous sheath pulled at ~11AM on \n -careful monitoring of BP, and if BP dropping or pt becoming\n tachycardic cardiology fellow should be paged (? of retroperitoneal\n bleeding)\n 3. Leukocytosis\n -likely related to STEMI, no signs of infection, hold abx\n 4. DM\n -continue insulin\n -continue ACE-I\n" }, { "category": "Physician ", "chartdate": "2158-08-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388469, "text": "Chief Complaint: chest pain\n HPI:\n 61 year old African-American female with a h/o CAD\n s/p MI, s/p 1v CABG , cholelithiasis, GERD, hypertension,\n type 2 diabetes mellitus who was in her usual state of health until 4am\n today. She suddenly woke up with diffuse chest pressure, shortness of\n breath, nausea, vomiting, and diaphoresis. She says this pain is\n different from the pain that she had with her previous MI. That was\n more L sided sharp pain, where as this was more diffuse pressure.\n .\n Her husband immediately brought her to the emergency department.\n At 6:50am her vitals were T 97.2 HR 99 BP 119/71 RR 16 96% on RA.\n EKG showed ST elevations in leads II, III, aVF with ST depressions in\n V2-V6. A Code STEMI was called. She received full dose , oxygen,\n load, heparin bolus, integrellin, morphine, and was started on a\n nitro gtt.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of paroxysmal\n nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or\n presyncope.\n .\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Aspirin 81 mg po daily\n 2. Carvedilol 3.125 mg po bid\n 3. Lisinopril 2.5 mg po daily\n 4. Pantoprazole 40 mg po daily\n 5. Thiamine 100 mg po daily\n 6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl\n Topical PRN itching.\n 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:\n 15-30 MLs PO QID (4 times a day) PRN chest pain.\n 8. Insulin Regular Human 100 unit/mL Solution Sig: Twenty Four\n (24) units Injection BREAKFAST (Breakfast).\n 9. NPH 32 units qAM, 10 units qPM.\n 10. Furosemide 10 mg po daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG: 1 vessel Saphenous vein graft to diagonal artery.\n \n -PERCUTANEOUS CORONARY INTERVENTIONS: See below\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n h/o atrial myxoma s/p surgical removal \n GERD.\n Chest pain syndrome\n History of stroke with residual mild left-sided\n hemiparesis and left facial tingling.\n History of left breast cyst, status post excision which\n was benign.\n Status post hysterectomy and unilateral oophorectomy.\n Statin-induced pancreatitis ()\n Carpal Tunnel\n Mother with DM, CAD (deceased)\n 3 brothers with DM\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives with husband, occasional tobacco use, no ETOH, no illicits\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n VS: BP=118/73 HR=95 RR=22 O2 sat= 98%\n GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No murmurs. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No LE edema. R groin, catheter still\n in place. 3x3cm hematoma. Not tender to palpation. No bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n [image002.jpg]\n Imaging: \n .\n The left atrium and right atrium are normal in cavity size. No left\n atrial mass/thrombus seen (best excluded by transesophageal\n echocardiography). Left ventricular wall thicknesses and cavity size\n are normal. Regional left ventricular wall motion is normal. Overall\n left ventricular systolic function is low normal (LVEF 50-55%). Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n structurally normal. There is no mitral valve prolapse. Mild (1+)\n mitral regurgitation is seen. There is borderline pulmonary artery\n systolic hypertension.\n Compared with the prior study (images reviewed) of , regional\n left ventricular systolic function is improved. No residual myxoma\n identified. The severity of mitral regurgitation is similar.\n C. Cath \n LAD: 40% mid, 60% diagonal origin\n LCx: 60% inferior branch of OM1\n RCA: long 90% mid with thrombus, 40% distally\n SVG: diagonal patent\n -thrombectomy of mid RCA and DES of mid RCA placed\n .\n CXR (my read): Cardiomegaly. Diaphragms well visualized. No\n effusions. Patchy infiltrates at bases -atelectasis vs. congestion,\n seen on prior CXR from .\n ECG: EKG: 9am\n NSR @ 93bpm. TWI in V4-V6, III and aVF. ST elevations in III and aVF.\n Lateral lead ST depressions.\n Assessment and Plan\n 61 yo F with history of DM2, CAD s/p 1v CABG, and HTN who presented to\n ED with STEMI this morning, s/p cath and DES placed to RCA.\n .\n # CORONARIES: Known CAD s/p 1v CABG. s/p c. cath this AM with DES\n placed to RCA.\n -full dose \n - 75mg po daily x1 year\n -lisinopril 2.5mg po daily\n -carvedilol 3.125mg po daily -titrate up to HR in 60s\n -trend CKs\n -post cath check 4-6 hours after removal of catheter\n .\n # PUMP: EF 50-55%. Patient takes 10mg po lasix for ankle edema, but\n denies orthopnea or PND. Currently appears euvolemic.\n -hold lasix for now. Would monitor I/Os with goal of keeping her net\n even\n .\n # RHYTHM: Currently NSR\n -monitor on telemetry\n .\n # Leukocytosis: WBC 14.4. Likely from STEMI. If patient develops\n fevers or develops worsening leukocytosis, would send blood cultures,\n UA, sputum cultures.\n .\n # DM2: Continue NPH 32 units in AM, 10 units in PM, per outpatient\n regimen.\n -SSI\n -qid fingersticks\n -diabetic diet\n .\n # GERD: Patient mentions that she has fairly severe GERD. Will hold\n Pantoprazole given that she is on , and try ranitidine while in\n house.\n .\n .\n FEN: Heart healthy, diabetic diet. No IV fluids. Replete electrolytes\n PRN.\n .\n ACCESS: PIV\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SQ\n -Pain management with tylenol PRN\n -Bowel regimen with colace PRN\n .\n CODE: FULL -confirmed with patient\n .\n COMM: husband\n .\n DISPO: CCU for now\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2158-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388577, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CHEST PAIN - At 08:00 PM\n pt c/o CP 12 lead done team eval pt morphine 2 mg IVP\nGROIN PAIN\n Patient with R groin pain this morning at hematoma site,\n improved from yesterday\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:15 PM\n Heparin Sodium (Prophylaxis) - 11:00 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 09:29 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: 36.1\nC (97\n HR: 74 (74 - 102) bpm\n BP: 98/55(66) {96/51(62) - 122/75(85)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.9 kg (admission): 71 kg\n Total In:\n 1,720 mL\n PO:\n 250 mL\n TF:\n IVF:\n 1,470 mL\n Blood products:\n Total out:\n 2,300 mL\n 480 mL\n Urine:\n 650 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -580 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n GENERAL: Alert, interactive, NAD.\n HEENT: EOMI, MMM.\n CARDIAC: RRR, normal S1, S2. No murmurs/gallops/rubs\n LUNGS: CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND, +BS.\n EXTREMITIES: No LE edema. R groin hematoma smaller in size than\n yesterday (<3cm) with tenderness, no bruit, femoral pulse palpable.\n PULSES: DP pulses palpable R>L, both present on Doppler.\n Labs / Radiology\n 226 K/uL\n 10.9 g/dL\n 228 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 139 mEq/L\n 33.3 %\n 14.5 K/uL\n [image002.jpg]\n 04:32 PM\n 11:31 PM\n 05:04 AM\n WBC\n 8.7\n 11.8\n 14.5\n Hct\n 36.0\n 34.3\n 33.3\n Plt\n \n Cr\n 1.0\n 1.0\n 0.9\n TropT\n 1.04\n 0.65\n Glucose\n 397\n 354\n 228\n Other labs: PT / PTT / INR:12.0/26.6/1.0, CK / CKMB /\n Troponin-T:288/41/0.65, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 61 yo F with history of DM2, CAD s/p 1v CABG, and HTN who presented to\n ED with STEMI this morning, s/p cath and DES placed to RCA.\n .\n MYOCARDIAL INFARCTION, ACUTE (STEMI): Known CAD s/p 1v CABG. s/p c.\n cath this AM with DES placed to RCA, peak CK 506 now downtrending.\n -Continue full dose ASA\n -Continue Plavix 75mg po daily x1 year\n -Continue lisinopril 2.5mg po daily\n -Carvedilol increased to 6.25mg recently, will monitor HR today and\n titrate up as necessary to maintain HR in 60s\n - PT consult\n .\n PUMP: EF 50-55%. Patient takes 10mg po lasix for ankle edema, but\n denies orthopnea or PND. Currently appears slightly fluid overloaded.\n -Lasix 20mg IV x1 today\n - Resume home Lasix 10mg po daily.\n .\n RHYTHM: Currently NSR\n -monitor on telemetry\n .\n Leukocytosis: WBC 14.4. Likely from STEMI. If patient develops\n fevers or develops worsening leukocytosis, would send blood cultures,\n UA, sputum cultures.\n .\n DM2: Continue NPH 32 units in AM, 10 units in PM, per outpatient\n regimen.\n -SSI\n -qid fingersticks\n -diabetic diet\n .\n GERD: Patient reports fairly severe GERD, holding Pantoprazole as pt\n on Plavix.\n - Continue Ranitidine.\n .\n FEN: Heart healthy, diabetic diet. No IV fluids. Replete electrolytes\n PRN.\n ACCESS: PIV\n PROPHYLAXIS:\n -DVT ppx with heparin SQ\n -Pain management with tylenol PRN\n -Bowel regimen with colace PRN\n CODE: FULL -confirmed with patient\n COMM: \n DISPO: Floor today\n ICU Care\n Nutrition: Heart healthy/diabetic diet.\n Glycemic Control:\n Lines: PIV\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT: Heparin SQ.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Pt\n status: Full\n Disposition: Floor today.\n" }, { "category": "Nursing", "chartdate": "2158-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388476, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388562, "text": "61 yo F w/ PMHx of DM, HTN, HL, stroke, and resection of atrial myxoma\n in (with one vessel bypass at this time) who awoke the morning\n of at ~4AM with crushing chest pain. She was brought to the\n ED where EKG showed ST elevations in inferior leads. A code STEMI\n was activated and the pt was brought to the cath lab where she was\n found to have an occlusion of her RCA. Prior to the intervention she\n received integrilin, heparin, , , and nitroglycerin. SBP >\n 100 in L arm. R arm noted to be much lower per report by art line BP\n higher in cath lab. Post procedure Pt denies chest pain. s/p DES to\n RCA with Angioseal to R groin c/b hematoma. Integrilin dc\nd in lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n NO CP, SOB .SR OCC PAC,BP 100 TO 110 SYSTOLIC.TOL CORREG,LISINOPRIL\n .SOFT HEMATOMA R GROIN CATH SITE ,DISTAL PULSES BY DOPPLER .SAT 100 RM\n AIR.20MG IV LASIX GIVEN FOR CRACKLES IN BASES.FOLEY ,VOIDED 400 CC\n GOOD APPETITE NO STOOL,COLACE GIVEN ,AM HCT STABLE,MG REPLETED .C/O\n PAIN IN R FEMORAL SITE WHEN MOVING,SEEN BY HO,TYLENOL GIVEN\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n STEMI\n Code status:\n Height:\n Admission weight:\n 71 kg\n Daily weight:\n 68.9 kg\n Allergies/Reactions:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Angina, CAD, Hypertension, MI, PVD\n Additional history: s/p CABG and resection of L atrial myxoma.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:102\n D:48\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 410 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 05:04 AM\n Potassium:\n 4.0 mEq/L\n 05:04 AM\n Chloride:\n 105 mEq/L\n 05:04 AM\n CO2:\n 26 mEq/L\n 05:04 AM\n BUN:\n 16 mg/dL\n 05:04 AM\n Creatinine:\n 0.9 mg/dL\n 05:04 AM\n Glucose:\n 228 mg/dL\n 05:04 AM\n Hematocrit:\n 33.3 %\n 05:04 AM\n Finger Stick Glucose:\n 176\n 12:00 PM\n Valuables / Signature\n Patient valuables: DENTURES ,CLOTHES ,GLASSES\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: F3\n Date & time of Transfer: 1400 \n Action:\n PT OOB,CARDIAC MEDS, LASIX GIVEN ,MI TEACHING\n Response:\n TOL INCREASE ACTIVITY , HR 67 P AM CORREG, TOL MEDS ,HAS UNDERSTANDING\n OF DX\n Plan:\n ADVANCE ACTIVITY ,CONTINUE TEACHING,MONITOR RESPONSE TO MEDS,FOLLOW\n FLUID BALANCE ,LYTES,HCT,ANY BLEEDING FROM R GROIN\n Diabetes Mellitus (DM), Type I\n Assessment:\n BS ELEVATED\n Action:\n NPH,HUMULOG INSULIN PER SCALE\n Response:\n BS 176 to 200S\n Plan:\n CLOSE BS MONITORING\n" }, { "category": "Physician ", "chartdate": "2158-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388563, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CHEST PAIN - At 08:00 PM\n pt c/o CP 12 lead done team eval pt morphine 2 mg IVP\nGROIN PAIN\n Patient with R groin pain this morning at hematoma site,\n improved from yesterday\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:15 PM\n Heparin Sodium (Prophylaxis) - 11:00 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 09:29 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: 36.1\nC (97\n HR: 74 (74 - 102) bpm\n BP: 98/55(66) {96/51(62) - 122/75(85)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.9 kg (admission): 71 kg\n Total In:\n 1,720 mL\n PO:\n 250 mL\n TF:\n IVF:\n 1,470 mL\n Blood products:\n Total out:\n 2,300 mL\n 480 mL\n Urine:\n 650 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -580 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.9 g/dL\n 228 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 139 mEq/L\n 33.3 %\n 14.5 K/uL\n [image002.jpg]\n 04:32 PM\n 11:31 PM\n 05:04 AM\n WBC\n 8.7\n 11.8\n 14.5\n Hct\n 36.0\n 34.3\n 33.3\n Plt\n \n Cr\n 1.0\n 1.0\n 0.9\n TropT\n 1.04\n 0.65\n Glucose\n 397\n 354\n 228\n Other labs: PT / PTT / INR:12.0/26.6/1.0, CK / CKMB /\n Troponin-T:288/41/0.65, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n DIABETES MELLITUS (DM), TYPE I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2158-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388647, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CALLED OUTTITLE:\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:45 AM\n Heparin Sodium (Prophylaxis) - 08:46 AM\n Furosemide (Lasix) - 10:01 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 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: 37\nC (98.6\n HR: 71 (71 - 89) bpm\n BP: 102/48(62) {102/48(62) - 114/65(78)} mmHg\n RR: 23 (18 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.9 kg (admission): 71 kg\n Total In:\n 410 mL\n PO:\n 360 mL\n TF:\n IVF:\n 50 mL\n Blood products:\n Total out:\n 1,200 mL\n 0 mL\n Urine:\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -790 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.9 g/dL\n 228 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 139 mEq/L\n 33.3 %\n 14.5 K/uL\n [image002.jpg]\n 04:32 PM\n 11:31 PM\n 05:04 AM\n WBC\n 8.7\n 11.8\n 14.5\n Hct\n 36.0\n 34.3\n 33.3\n Plt\n \n Cr\n 1.0\n 1.0\n 0.9\n TropT\n 1.04\n 0.65\n Glucose\n 397\n 354\n 228\n Other labs: PT / PTT / INR:12.0/26.6/1.0, CK / CKMB /\n Troponin-T:288/41/0.65, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Microbiology: WOUND CULTURE (Final ):\n ENTEROBACTER CLOACAE. MODERATE GROWTH.\n This organism may develop resistance to third generation\n cephalosporins during prolonged therapy. Therefore, isolates\n that\n are initially susceptible may become resistant within three to\n four days after initiation of therapy. For serious\n infections,\n repeat culture and sensitivity testing may therefore be\n warranted\n if third generation cephalosporins were used.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ENTEROBACTER CLOACAE\n |\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- <=1 S\n CEFTRIAXONE----------- <=1 S\n CIPROFLOXACIN---------<=0.25 S\n GENTAMICIN------------ <=1 S\n MEROPENEM-------------<=0.25 S\n PIPERACILLIN---------- <=4 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- <=1 S\n -------------------------------------------\n 10:15 am SWAB Source: Right ankle.\n **FINAL REPORT **\n WOUND CULTURE (Final ):\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n Assessment and Plan\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n DIABETES MELLITUS (DM), TYPE I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2158-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388666, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CHEST PAIN - At 08:00 PM\n pt c/o CP 12 lead done team eval pt morphine 2 mg IVP\nGROIN PAIN\n Patient with R groin pain this morning at hematoma site,\n improved from yesterday\n Allergies:\n Penicillins\n Hives;\n Iodine; Iodine Containing\n Hives;\n Lipitor (Oral) (Atorvastatin Calcium)\n ? pancreatitis;\n Aspirin\n Abdominal pain;\n Zocor (Oral) (Simvastatin)\n pancreatitis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:15 PM\n Heparin Sodium (Prophylaxis) - 11:00 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 09:29 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: 36.1\nC (97\n HR: 74 (74 - 102) bpm\n BP: 98/55(66) {96/51(62) - 122/75(85)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.9 kg (admission): 71 kg\n Total In:\n 1,720 mL\n PO:\n 250 mL\n TF:\n IVF:\n 1,470 mL\n Blood products:\n Total out:\n 2,300 mL\n 480 mL\n Urine:\n 650 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -580 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n GENERAL: Alert, interactive, NAD.\n HEENT: EOMI, MMM.\n CARDIAC: RRR, normal S1, S2. No murmurs/gallops/rubs\n LUNGS: CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND, +BS.\n EXTREMITIES: No LE edema. R groin hematoma smaller in size than\n yesterday (<3cm) with tenderness, no bruit, femoral pulse palpable.\n PULSES: DP pulses palpable R>L, both present on Doppler.\n Labs / Radiology\n 226 K/uL\n 10.9 g/dL\n 228 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 139 mEq/L\n 33.3 %\n 14.5 K/uL\n [image002.jpg]\n 04:32 PM\n 11:31 PM\n 05:04 AM\n WBC\n 8.7\n 11.8\n 14.5\n Hct\n 36.0\n 34.3\n 33.3\n Plt\n \n Cr\n 1.0\n 1.0\n 0.9\n TropT\n 1.04\n 0.65\n Glucose\n 397\n 354\n 228\n Other labs: PT / PTT / INR:12.0/26.6/1.0, CK / CKMB /\n Troponin-T:288/41/0.65, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 61 yo F with history of DM2, CAD s/p 1v CABG, and HTN who presented to\n ED with STEMI this morning, s/p cath and DES placed to RCA.\n .\n MYOCARDIAL INFARCTION, ACUTE (STEMI): Known CAD s/p 1v CABG. s/p c.\n cath this AM with DES placed to RCA, peak CK 506 now downtrending.\n -Continue full dose ASA\n -Continue Plavix 75mg po daily x1 year\n -Continue lisinopril 2.5mg po daily\n -Carvedilol increased to 6.25mg recently, will monitor HR today and\n titrate up as necessary to maintain HR in 60s\n - PT consult\n .\n PUMP: EF 50-55%. Patient takes 10mg po lasix for ankle edema, but\n denies orthopnea or PND. Currently appears slightly fluid overloaded.\n -Lasix 20mg IV x1 today\n - Resume home Lasix 10mg po daily.\n .\n RHYTHM: Currently NSR\n -monitor on telemetry\n .\n Leukocytosis: WBC 14.4. Likely from STEMI. If patient develops\n fevers or develops worsening leukocytosis, would send blood cultures,\n UA, sputum cultures.\n .\n DM2: Continue NPH 32 units in AM, 10 units in PM, per outpatient\n regimen.\n -SSI\n -qid fingersticks\n -diabetic diet\n .\n GERD: Patient reports fairly severe GERD, holding Pantoprazole as pt\n on Plavix.\n - Continue Ranitidine.\n .\n FEN: Heart healthy, diabetic diet. No IV fluids. Replete electrolytes\n PRN.\n ACCESS: PIV\n PROPHYLAXIS:\n -DVT ppx with heparin SQ\n -Pain management with tylenol PRN\n -Bowel regimen with colace PRN\n CODE: FULL -confirmed with patient\n COMM: \n DISPO: Floor today\n ICU Care\n Nutrition: Heart healthy/diabetic diet.\n Glycemic Control:\n Lines: PIV\n 18 Gauge - 09:58 AM\n Prophylaxis:\n DVT: Heparin SQ.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Pt\n status: Full\n Disposition: Floor today.\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 Recovering from acute inferior ST elevation MI\n Small groin hematoma\n Above discussed extensively with patient.\n Date/time of service 9/28/9 at 1300.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:25 ------\n" }, { "category": "Radiology", "chartdate": "2158-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100003, "text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? free air under diaphragm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with stemi\n REASON FOR THIS EXAMINATION:\n ? free air under diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: STEMI, evaluate for free air under the diaphragm.\n\n COMPARISON: .\n\n BEDSIDE UPRIGHT RADIOGRAPH OF THE CHEST: There is no evidence of\n pneumoperitoneum. The lungs are clear without focal consolidations, pleural\n effusions or pneumothorax. There is no pulmonary edema. Moderate\n cardiomegaly is stable.\n\n Median sternotomy wires and mediastinal clips are unchanged. There are\n minimal aortic arch calcifications.\n\n IMPRESSION: No evidence of pneumoperitoneum. Stable moderate cardiomegaly.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2111-01-05 00:00:00.000", "description": "Intensivist Note", "row_id": 609807, "text": "SICU\n HPI:\n 57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis.\n Chief complaint:\n MRSA infection, osteo/discitis\n PMHx:\n :-Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Current medications:\n 24 Hour Events:\n FEVER - 102.5\nF - 05:00 PM\n : cx w. MRSA. CPS - inc fent patch. Still febrile.\n Post operative day:\n Anterior cervical discectomies C4-5, C5-6, C6-7, C5 corpectomy,\n C6 corpectomy, C4-7 fusion with allograft and plating\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 09:30 PM\n Hydromorphone (Dilaudid) - 02:30 AM\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: 39.2\nC (102.5\n T current: 37.4\nC (99.3\n HR: 83 (82 - 127) bpm\n BP: 81/45(60) {81/45(59) - 146/73(99)} mmHg\n RR: 12 (9 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 3,146 mL\n 523 mL\n PO:\n 180 mL\n Tube feeding:\n 259 mL\n 55 mL\n IV Fluid:\n 2,527 mL\n 468 mL\n Blood products:\n Total out:\n 2,670 mL\n 160 mL\n Urine:\n 2,670 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 476 mL\n 363 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Anxious, Cachectic, Distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished: ),\n (Sternum: Stable )\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 119 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 110 mEq/L\n 142 mEq/L\n 25.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 02:51 AM\n 03:15 AM\n 02:28 AM\n WBC\n 5.2\n 7.3\n 7.6\n Hct\n 29.5\n 27.6\n 25.1\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.5\n TCO2\n 27\n 28\n Glucose\n 111\n 100\n 119\n Other labs: PT / PTT / INR:13.8/33.5/1.2, ALT / AST:14/15, Alk-Phos / T\n bili:192/0.4, Albumin:3.0 g/dL, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O EATING DISORDER (INCLUDING ANOREXIA NERVOSA, BULEMIA), NAUSEA /\n VOMITING, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), OSTEOMYELITIS\n Assessment and Plan: 57 year old female with extensive pmh including\n relatively recent esphageal perforation and PICC associated MRSA/MSSA\n bacteremia presenting with neck pain and OSH MRI that showed C5-C6\n osteomyelitis/discitis now s/p Anterior cervical discectomies C4-5,\n C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with allograft\n and plating (). Possible plan for posterior fusion on .\n Neurologic: Chronic pain issues. Anxiety. Somatoform disorder. Chronic\n pain consulted. Pain controlled on dilaudid PCA. Req iv dilaudid for\n btp. On fioricet, methocarbamol, lyrica, and fentanyl patch. Ativan and\n trazodone for anxiety. Pt possibly returning to OR for posterior\n cervical fusion Monday, Tuesday. Neuro checks q4hr. ? psych consult for\n somoatoform dis\n Cardiovascular: Tachy. Baseline hypotension. SBP<160 stable\n hemodynamics. no vasopressors, allow autoregulation\n Pulmonary: Extubated . Stable on NC\n Gastrointestinal/Abdomen: Gastroparesis s/p G-J tube. H/o eating\n disorder and tears from vomiting. Nausea adequately\n controlled on phenergan, reglan, scopolamine. Full bowel regimen\n Nutrition: Vivonex TEN Full strength goal 20ml/hr. (20ml/hr is pt's\n home rate). Clears diet.\n Renal: monitor UOP. Cr WNL. Foley\n Hematology: hct stable 27.6. On SQH\n Endocrine: RISS\n ID: Osteomyelitis - MRSA on surgical tissue cx. Febrile. Follow up\n BCX/UCX/Sputum CX. Vancomycin. Follow troughs. ID following. Consider\n dc fem line, dc picc - resite\n Lines / Tubes / Drains: R femoral TLC, L arm PICC. A-line, D/C Foley.\n new picc pending\n Wounds: ASPEN collar at all times\n Imaging:\n Fluids: KVO\n Consults: Neurosurgery\n Billing Diagnosis: Osteomyelitis; gastroparesis, chronic pain\n Prophylaxis:\n DVT: SCD, SQH\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:Step down\n Time\n" }, { "category": "Physician ", "chartdate": "2111-01-06 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 609974, "text": "HPI:\n 57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis.\n 24 Hour Events:\n FEVER - 102.5\nF - 05:00 PM\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Vancomycin - 08:20 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 PM\n Hydromorphone (Dilaudid) - 12:29 AM\n Heparin Sodium (Prophylaxis) - 12:34 AM\n Other medications:\n Flowsheet Data as of 12:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.5\n Tcurrent: 36.4\nC (97.6\n HR: 93 (82 - 130) bpm\n BP: 105/62(79) {81/45(60) - 162/93(116)} mmHg\n RR: 10 (10 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 3,282 mL\n 137 mL\n PO:\n 270 mL\n 60 mL\n TF:\n 484 mL\n 31 mL\n IVF:\n 2,248 mL\n 46 mL\n Blood products:\n Total out:\n 2,860 mL\n 220 mL\n Urine:\n 2,860 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 422 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\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: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 119 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 110 mEq/L\n 142 mEq/L\n 25.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 02:51 AM\n 03:15 AM\n 02:28 AM\n WBC\n 5.2\n 7.3\n 7.6\n Hct\n 29.5\n 27.6\n 25.1\n Plt\n \n Cr\n 0.4\n 0.4\n 0.5\n TCO2\n 27\n 28\n Glucose\n 111\n 100\n 119\n Other labs: PT / PTT / INR:13.8/33.5/1.2, ALT / AST:14/15, Alk Phos / T\n Bili:192/0.4, Albumin:3.0 g/dL, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O EATING DISORDER (INCLUDING ANOREXIA NERVOSA, BULEMIA), NAUSEA /\n VOMITING, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), OSTEOMYELITIS\n ASSESSMENT:57 year old female with extensive pmh including relatively\n recent esphageal perforation and PICC associated MRSA/MSSA bacteremia\n presenting with neck pain and OSH MRI that showed C5-C6\n osteomyelitis/discitis now s/p Anterior cervical discectomies C4-5,\n C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with allograft\n and plating ().\n Neurologic: Chronic pain issues. Anxiety. Somatoform disorder. Chronic\n pain consulted. Pain controlled on dilaudid PCA. Req iv dilaudid for\n btp. On fioricet, methocarbamol, lyrica, and fentanyl patch. Ativan and\n trazodone for anxiety. Neuro checks q4hr. ? psych consult for\n somoatoform dis\n Cardiovascular: Tachy. Baseline hypotension. SBP<160 stable\n hemodynamics. no vasopressors, allow autoregulation\n Pulmonary: Extubated . Stable on NC CXR fine.\n Gastrointestinal/Abdomen: Gastroparesis s/p G-J tube. H/o eating\n disorder and tears from vomiting. Nausea adequately\n controlled on phenergan, reglan, scopolamine. Full bowel regimen\n Nutrition: Vivonex TEN Full strength goal 20ml/hr. (20ml/hr is pt's\n home rate)increased goal to 50 as per dietician. Clears diet.\n Will decrease flush to 30cc, as tube is in jejunum.\n Renal: monitor UOP. Cr WNL.\n Hematology: hct stable 25.1. On SQH\n Endocrine: RISS\n ID: Osteomyelitis - MRSA on surgical tissue cx. Febrile. Follow up\n BCX/UCX/Sputum CX. Vancomycin. Follow troughs. ID following.still\n spikes fever. Consider dc fem line, dc picc - resite\n Lines / Tubes / Drains: R femoral TLC, L arm PICC. A-line, Foley. new\n picc pending\n Wounds: ASPEN collar at all times\n Imaging:\n Fluids: KVO\n Consults: Neurosurgery\n Billing Diagnosis: Osteomyelitis; gastroparesis, chronic pain\n Prophylaxis:\n DVT: SCD, SQH\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU-step down\n Nutrition:\n Vivonex (Full) - 02:56 PM 50 mL/hour\n PICC Line - 06:29 PM\n Arterial Line - 06:30 PM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609516, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V , extensive psych history including\n eating disorder (pt denies). Transferred from with 6 weeks\n neck pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in recent past). Afebrile\n and WBC here OK; ESR 40's. No growth on OSH blood cultures. Initially\n on Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to floor for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrographin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. . J collar in place. To OR \n to fuse and clean out her cervical spine.\n Osteomyelitis\n Assessment:\n Requiring large amts of sedation. Opens eyes spontaneously,\n follows commands.\n Intubated overnoc\n BUE\ns lift and fall back, normal strength BLE\n J collar in place\n JP draining small amts s/s drainage\n Anterior neck incision with DSD C/D/I\n G/J tube in place. G tube to gravity. J tube clogged.\n Action:\n Neuro checks q 4\n Post op CT of C-spine done\n Weaning PPF to off\n Dilaudid dose increased\n Papain given to unclog J tube to give meds. Unable to start\n TF\ns as Vivonex not available. aware.\n Response:\n Neuro exam unchanged\n J tube patent\n Plan:\n Extubate this am\n Cont neuro checks\n Pain control\n Restart TF\n" }, { "category": "Nursing", "chartdate": "2111-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609787, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n Some sort of Munchausen\ns syndrome\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with acute and chronic pain, very demanding of pain medications most\n of the time, rates pain at .\n Action:\n Medicated with Dilauded PCA, Dilauded IV push, Ativan, Fioricet and\n Fentanyl patch.\n Trazadone given late evening.\n Response:\n Pt able to sleep for periods overnight, especially when given full 2mg\n dose of Dilauded IV. Using PCA a lot when awake, and requesting\n dialuded Q1-2hrs aswell.\n Plan:\n Continue to medicate as needed for pain.\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609593, "text": "Extubated in a.m, tolerating well.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain of on pain scale. Describes pain as sometimes\n incisional and other times\nall over\n or other times as abdominal.\n Action:\n Tx\nd wtith fentanyl, dilaudid prn with continued increases in doses and\n frequencies. Started fentanyl PCA and continued with dilaudid prn.\n Fentanyl patch in place.\n Response:\n Continues to c/o of pain of but appears comfortable and dozing at\n times.\n Plan:\n Continue with PCA, ? increase dose, provide emotional comfort.\n Nausea / vomiting\n Assessment:\n Extensive hx of n/v s/t gastroparesis s/t eating disorder (denies). J\n tube in place but blocked. Abd soft/distended. Clear liquids PO and TF\n via j-tube. Pt states Ativan helps with nausea.\n Action:\n Tx n/v with raglan, phenergan, Ativan. Attempt to unblock j-tube with\n papain, pepsi. Pulled back slightly to r/o positional blockage.\n Response:\n J-tube no longer blocked, placement reconfirmed with x-ray with 20 ccs\n gastrografen.\n Plan:\n Restart meds and tube feeds via j-tube, continue to tx N/V aggressively\n as ordered.\n" }, { "category": "Nursing", "chartdate": "2111-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609878, "text": "57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis/discitis (MRSA.)\n PMHx:\n Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. reporting high levels of pain from . Pt. vitals are\n stable/at baseline and she is noted to reach for items at bedside and\n move freely in bed when alone in room.\n Action:\n Pt. receiving 1-2mg IV dilaudid Q1-2 hrs as documented, utilizing\n dilaudid PCA. Pt. also receiving fioricet Q6hrs, ativan Q4hrs, and\n muscle relaxors ATC.\n Response:\n Lowest pain level thus far today . Pt. states an acceptable level\n for her is . ?Reliabilty of subjective information.\n Plan:\n Medicated pre CPS rec\ns. Monitor and treat as indicated.\n Osteomyelitis\n Assessment:\n Pt. neurologically intact, able to lift and hold all extremeties (this\n is better assessed during ADL\ns or if items on bedside table need to be\n reached, otherwise pt. states\nI can\nt lift my arms\n.) Pt. afebrile,\n but having some shaking chills this eve with hyperdynamic vital signs.\n Skin warm, dry. No distress noted today.\n Action:\n Neuro checks Q4hrs. Pain control as above. Vanco Q12hrs. Collar\n care done this eve. Independence encouraged. OOB to chair. IS,\n coughing/deep breathing encouraged.\n Response:\n Pt. remains intact. Presently hyperdynamic. Pt. noted to complete\n simple ADL\ns on her own.\n Plan:\n Continue to monitor and treat as indicated. Transfer to SDU when bed\n available.\n" }, { "category": "Physician ", "chartdate": "2111-01-05 00:00:00.000", "description": "Intensivist Note", "row_id": 609782, "text": "SICU\n HPI:\n 57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis.\n Chief complaint:\n MRSA infection, osteo/discitis\n PMHx:\n :-Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Current medications:\n 24 Hour Events:\n FEVER - 102.5\nF - 05:00 PM\n : cx w. MRSA. CPS - inc fent patch. Still febrile.\n Post operative day:\n Anterior cervical discectomies C4-5, C5-6, C6-7, C5 corpectomy,\n C6 corpectomy, C4-7 fusion with allograft and plating\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 09:30 PM\n Hydromorphone (Dilaudid) - 02:30 AM\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: 39.2\nC (102.5\n T current: 37.4\nC (99.3\n HR: 83 (82 - 127) bpm\n BP: 81/45(60) {81/45(59) - 146/73(99)} mmHg\n RR: 12 (9 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 3,146 mL\n 523 mL\n PO:\n 180 mL\n Tube feeding:\n 259 mL\n 55 mL\n IV Fluid:\n 2,527 mL\n 468 mL\n Blood products:\n Total out:\n 2,670 mL\n 160 mL\n Urine:\n 2,670 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 476 mL\n 363 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Anxious, Cachectic, Distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished: ),\n (Sternum: Stable )\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 119 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 110 mEq/L\n 142 mEq/L\n 25.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 02:51 AM\n 03:15 AM\n 02:28 AM\n WBC\n 5.2\n 7.3\n 7.6\n Hct\n 29.5\n 27.6\n 25.1\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.5\n TCO2\n 27\n 28\n Glucose\n 111\n 100\n 119\n Other labs: PT / PTT / INR:13.8/33.5/1.2, ALT / AST:14/15, Alk-Phos / T\n bili:192/0.4, Albumin:3.0 g/dL, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O EATING DISORDER (INCLUDING ANOREXIA NERVOSA, BULEMIA), NAUSEA /\n VOMITING, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), OSTEOMYELITIS\n Assessment and Plan: 57 year old female with extensive pmh including\n relatively recent esphageal perforation and PICC associated MRSA/MSSA\n bacteremia presenting with neck pain and OSH MRI that showed C5-C6\n osteomyelitis/discitis now s/p Anterior cervical discectomies C4-5,\n C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with allograft\n and plating (). Possible plan for posterior fusion on .\n Neurologic: Chronic pain issues. Anxiety. Somatoform disorder. Chronic\n pain consulted. Pain controlled on dilaudid PCA. Req iv dilaudid for\n btp. On fioricet, methocarbamol, lyrica, and fentanyl patch. Ativan and\n trazodone for anxiety. Pt possibly returning to OR for posterior\n cervical fusion Monday, Tuesday. Neuro checks q4hr. ? psych consult for\n somoatoform dis\n Cardiovascular: Tachy. Baseline hypotension. SBP<160 stable\n hemodynamics. no vasopressors, allow autoregulation\n Pulmonary: Extubated . Stable on NC\n Gastrointestinal/Abdomen: Gastroparesis s/p G-J tube. H/o eating\n disorder and tears from vomiting. Nausea adequately\n controlled on phenergan, reglan, scopolamine. Full bowel regimen\n Nutrition: Vivonex TEN Full strength goal 20ml/hr. (20ml/hr is pt's\n home rate). Clears diet.\n Renal: monitor UOP. Cr WNL. Foley\n Hematology: hct stable 27.6. On SQH\n Endocrine: RISS\n ID: Osteomyelitis - MRSA on surgical tissue cx. Febrile. Follow up\n BCX/UCX/Sputum CX. Vancomycin. Follow troughs. ID following. Consider\n dc fem line, dc picc - resite\n Lines / Tubes / Drains: R femoral TLC, L arm PICC. A-line, Foley. new\n picc pending\n Wounds: ASPEN collar at all times\n Imaging:\n Fluids: KVO\n Consults: Neurosurgery\n Billing Diagnosis: Osteomyelitis; gastroparesis, chronic pain\n Prophylaxis:\n DVT: SCD, SQH\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU\n Time: 35 min\n" }, { "category": "Nursing", "chartdate": "2111-01-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 609876, "text": "57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis/discitis (MRSA.)\n PMHx:\n Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. reporting high levels of pain from . Pt. vitals are\n stable/at baseline and she is noted to reach for items at bedside and\n move freely in bed when alone in room.\n Action:\n Pt. receiving 1-2mg IV dilaudid Q1-2 hrs as documented, utilizing\n dilaudid PCA. Pt. also receiving fioricet Q6hrs, ativan Q4hrs, and\n muscle relaxors ATC.\n Response:\n Lowest pain level thus far today . Pt. states an acceptable level\n for her is . ?Reliabilty of subjective information.\n Plan:\n Medicated pre CPS rec\ns. Monitor and treat as indicated.\n Osteomyelitis\n Assessment:\n Pt. neurologically intact, able to lift and hold all extremeties (this\n is better assessed during ADL\ns or if items on bedside table need to be\n reached, otherwise pt. states\nI can\nt lift my arms\n.) Pt. afebrile,\n but having some shaking chills this eve with hyperdynamic vital signs.\n Skin warm, dry. No distress noted today.\n Action:\n Neuro checks Q4hrs. Pain control as above. Vanco Q12hrs. Collar\n care done this eve. Independence encouraged. OOB to chair. IS,\n coughing/deep breathing encouraged.\n Response:\n Pt. remains intact. Presently hyperdynamic. Pt. noted to complete\n simple ADL\ns on her own.\n Plan:\n Continue to monitor and treat as indicated. Transfer to SDU when bed\n available.\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609943, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt. reporting high levels of pain from . Pain\n constant at neck down both arms/both legs/back\n Pt states when she is at home she lives w/ a pain level of\n \n Pt neuro exam when asked to perform: lifts and holds\n arms/weak grasps/lifts and holds legs in bent position. Pt appears weak\n by exam but noted to reach for items on BS table and move freely in bed\n when alone\n Chronic pain service following patient.\n Ordered for Transfer to Neuro step down, no bed available.\nI have to go to step-down unit because the nurses \nt have time to\n give me all my meds on a regular floor\n Complete bowel regime given on day shift including\n Lactulose/Ducc supp. BS hypoactive\n J-tube w/ Vivonex at 30cc/hr\n Action:\n Receiving 2mg IV dilaudid Q2 hrs as documented. Not\n utilizing dilaudid PCA max capacity. Pt noted to be falling asleep when\n left alone but easily arousable\n Frequently questions nursing when next\n narcotic/anti-emetic/benzo\ns are due to be administrated\n Scopolamine/Fentanyl patch intact\n Vivonex titrated to goal rate of 50cc/hr\n Pt w/ no reports of nausea or headache t/o evening\n Trazodone not admin PRN d/t pt sleeping when no one in room\n Response:\n Lowest pain level reported . No change in pain level\n even when bolus dilaudid admin. ?Reliabilty of subjective\n information.\n Pt appears in NAD. Appeared to be moving freely and sleeping\n majority of night\n Plan:\n Medicated pre CPS rec\n Monitor and treat as indicated.\n Aggressive bowel regime\n ?Psych consult\n Osteomyelitis\n Assessment:\n Pt. neurologically intact, able to lift and hold all\n extremeties (this is better assessed during ADL\ns or if items on\n bedside table need to be reached, otherwise pt. states\nI can\nt lift my\n arms\n Pt spiked temp on last evening to 103.5. BCx x2\n sent/UA/UCx. Still need sputum\n Temp at beginning of shift 100.6. Husband made aware of temp\n per patient request\n LS primarily diminished t/o. When pt asked to deep\n cough/breath she states\nm too weak\n O2 saturation stable o 2Liters via NC\n Action:\n Neuro checks Q4hrs. Pain control as above.\n Vanco Q12hrs. ID following\n IS, coughing/deep breathing encouraged. Pt previously noted\n to reach 750ml w/ IS on day shift but only would reach 500. Sounds\n like she is able to cough up phlegm but does not expectorate it\n Response:\n Pt neurologically remains intact.\n Afebrile WBC down 5.8 (7.6)\n Pt. noted to complete simple ADL\ns on her own.\n Plan:\n Continue to monitor and treat as indicated.\n Pulm toilet. Encourage OOB to chair for atleast 2hrs periods\n ID to contact husband regarding per husband requests\n Cultures pending\n Transfer to SDU when bed available.\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609934, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt. reporting high levels of pain from . Pain\n constant at neck down both arms/both legs/back\n Pt states when she is at home she lives w/ a pain level of\n \n Pt neuro exam when asked to perform: lifts and holds\n arms/weak grasps/lifts and holds legs in bent position. Pt appears weak\n by exam but noted to reach for items on BS table and move freely in bed\n when alone\n Chronic pain service following patient.\n Ordered for Transfer to Neuro step down, no bed available.\nI have to go to step-down unit because the nurses \nt have time to\n give me all my meds on a regular floor\n Complete bowel regime given on day shift including\n Lactulose/Ducc supp. BS hypoactive\n J-tube w/ Vivonex at 30cc/hr\n Action:\n Receiving 2mg IV dilaudid Q2 hrs as documented. Not\n utilizing dilaudid PCA max capacity. Pt noted to be falling asleep when\n left alone but easily arousable\n Frequently questions nursing when next\n narcotic/anti-emetic/benzo\ns are due to be administrated\n Scopolamine/Fentanyl patch intact\n Vivonex titrated to goal rate of 50cc/hr\n Pt w/ no reports of nausea or headache t/o evening\n Trazodone not admin PRN d/t pt sleeping when no one in room\n Response:\n Lowest pain level reported . No change in pain level\n even when bolus dilaudid admin. ?Reliabilty of subjective\n information.\n Pt appears in NAD. Appeared to be moving freely and sleeping\n majority of night\n Plan:\n Medicated pre CPS rec\n Monitor and treat as indicated.\n ?Psych consult\n Osteomyelitis\n Assessment:\n Pt. neurologically intact, able to lift and hold all\n extremeties (this is better assessed during ADL\ns or if items on\n bedside table need to be reached, otherwise pt. states\nI can\nt lift my\n arms\n Pt spiked temp on last evening to 103.5. BCx x2\n sent/UA/UCx. Still need sputum\n Temp at beginning of shift 100.6. Husband made aware of temp\n per patient request\n LS primarily diminished t/o. When pt asked to deep\n cough/breath she states\nm too weak\n O2 saturation stable o 2Liters via NC\n Action:\n Neuro checks Q4hrs. Pain control as above.\n Vanco Q12hrs. ID following\n IS, coughing/deep breathing encouraged. Pt previously noted\n to reach 750ml w/ IS on day shift but only would reach 500. Sounds\n like she is able to cough up phlegm but does not expectorate it\n Response:\n Pt. remains intact. Presently hyperdynamic. Pt. noted to complete\n simple ADL\ns on her own.\n Plan:\n Continue to monitor and treat as indicated. Transfer to SDU when bed\n available.\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610037, "text": "Osteomyelitis\n Assessment:\n Afebrile. A&O x3. Able to lift and hold all extremities. LCTA\n diminished at bases. On 2L O2 via NC. Using IS with good technique.\n Action:\n Neuro checks q4 hours. Antibiotics as ordered\n vanco dose increased.\n Encouraged C&DB. OOB to chair. ID spoke with family regarding\n medication regimen.\n Response:\n Pt stable.\n Plan:\n Continue to follow temperature curve. Pulmonary hygiene. Check vanco\n trough in am. Transfer to SDU when bed available.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting constant pain at rest. Pain in neck, back and both\n arms. Able to brush hair, wash face and brush teeth with assist for\n set-up only.\n Action:\n Receiving 2mg dilaudid q2 hours as ordered. Using Dilaudid PCA\n appropriately. Fentanyl patch on as ordered. Receiving muscle\n relaxant and Lyrica as ordered. Repositioned in bed q 2 hours.\n Provided emotional support.\n Response:\n Pt noted to be dozing in bed/chair after pain medication\n administration, though per pt in constant pain.\n Plan:\n Continue to follow chronic pain recommendations. Emotional support.\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610041, "text": "57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis/discitis (MRSA.)\n PMHx:\n Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Osteomyelitis\n Assessment:\n Afebrile. A&O x3. Able to lift and hold all extremities. LSCTA\n diminished at bases. On 2L O2 via NC. Using IS with good technique.\n Action:\n Neuro checks q4 hours. Antibiotics as ordered\n vanco dose increased.\n Encouraged C&DB. OOB to chair. ID spoke with family regarding\n medication regimen.\n Response:\n Pt stable.\n Plan:\n Continue to follow temperature curve. Pulmonary hygiene. Check vanco\n trough in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting constant pain at rest. Pain in neck, back and both\n arms. Able to brush hair, wash face and brush teeth with assist for\n set-up only.\n Action:\n Using Dilaudid PCA appropriately. Receiving 2mg dilaudid prn for\n breakthrough pain. Fentanyl patch on as ordered. Receiving muscle\n relaxant and Lyrica as ordered. Repositioned in bed q 2 hours.\n Provided emotional support.\n Response:\n Pt noted to be dozing in bed/chair after pain medication\n administration, though per pt in constant pain.\n Plan:\n Continue to follow chronic pain recommendations. Emotional support.\n" }, { "category": "Physician ", "chartdate": "2111-01-03 00:00:00.000", "description": "Intensivist Note", "row_id": 609476, "text": "SICU\n HPI:\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n unable to asess neuro exam because she doesn't cooperate. some sort of\n munchausen's syndrome.\n Chief complaint:\n Transferred from with 6 weeks neck pain, 3 weeks increasing\n weakness. MRI there -> osteo/discitis in C5-C6. Reportedly no epidural\n abscess.\n PMHx:\n :-Perforated esophagus vs tear in and (secondary\n to emesis gastroparesis)\n -mechanical ventilation / intubation \n -MRSA bacteremia /\n -Gastroparesis (likely narcotic induced vs idiopathic): History\n of TPN, G-J tube for gastroparesis/ po intake supported by tube feeds\n -Supraclavicular clot / treated by \"balloon\"\n -Childhood constipation\n -chronic chest pain\n -History eating disorder\n -Narcotic induced ileus\n -History of laxative abuse and ? eating disorder\n -RUE DVT - line associated\n -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy\n -GERD\n -C. difficile colitis\n -Mild esophagitis\n -Cholecystitis\n -Hysterectomy for uterine cancer \n -Migraine headaches\n -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Current medications:\n . 2. 20 mEq Potassium Chloride / 1000 mL NS 3.\n Acetaminophen-Caff-Butalbital 4. Acetaminophen 5. DiCYCLOmine\n 6. Docusate Sodium (Liquid) 7. Fentanyl Patch 8. HYDROmorphone\n (Dilaudid) 9. Heparin Flush (10 units/ml)\n 10. HydrOXYzine 11. 12. Lansoprazole Oral Disintegrating Tab 13.\n Lorazepam 14. Metoclopramide 15. Methocarbamol\n 16. Multivitamins W/minerals 17. Papain 2.5 % Solution 18. Pregabalin\n 19. Promethazine 20. Scopolamine Patch\n 24 Hour Events:\n F/up CAT scan\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Infusions:\n Propofol - 90 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:45 PM\n Other medications:\n Flowsheet Data as of 01:26 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: 36.7\nC (98\n HR: 66 (66 - 94) bpm\n RR: 12 (12 - 14) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 3,035 mL\n 138 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,035 mL\n 138 mL\n Blood products:\n Total out:\n 1,520 mL\n 0 mL\n Urine:\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,515 mL\n 138 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): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SPO2: 99%\n ABG: ////\n Ve: 5.1 L/min\n Physical Examination\n General Appearance: No acute distress, neck in collar\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: ASSESSMENT:57 year old white female with extensive\n pmh including relatively recent esphageal perforation and PICC\n associated MRSA bacteremia presenting with neck pain and OSH MRI that\n shows C5-C6 osteomyelitis/discitis.s/p Anterior cervical discectomies\n C4-5, C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with\n allograft and plating ()\n plan for possible posterior fusion on depending on post op scan\n Neurologic:sedated with propofol\n Cardiovascular:stable hemodynamics.no vasopressors\n Pulmonary:CMV/AC 50 % fio2\n Gastrointestinal / Abdomen:soft,J tube .Patient has h/o severe nausea\n and vomiting leading to esophageal tears.Phenargan works best for her.\n Nutrition: Vivonex TEN Full strength goal 50\n Renal:monitor UO\n Hematology:hct 32\n Endocrine:\n ID: No abx until cultures are back (no signs of infection in the OR)\n Lines / Tubes / Drains:a line/PICC/J tube/foley\n Wounds:ASPEN collar at all times\n Imaging:f/up rpt CT scan final report\n Fluids:NS + 20 k @ 75CC/HR\n Consults:neurosurgery\n Billing Diagnosis:s/p Anterior cervical discectomies C4-5, C5-6, C6-7,\n C5 corpectomy, C6 corpectomy, C4-7 fusion with allograft and plating\n Prophylaxis:\n DVT:SCD\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Lines:\n Multi Lumen - 06:28 PM\n PICC Line - 06:29 PM\n Arterial Line - 06:30 PM\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2111-01-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 609458, "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: Yes\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: 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: /\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 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 Comments: Extubate tomorrow am\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR; Comments: Post Op pt\n" }, { "category": "General", "chartdate": "2111-01-02 00:00:00.000", "description": "Generic Note", "row_id": 609460, "text": "TITLE:\n Pt is 57y/o female s/p anterior cervical discectomies C4-5, 5-6,. C5\n Corpectomy, C6 Corpectomy, C4-7 fusion w/ allograft and plating.\n Received pt from OR intubated on Propofol gtt at 100mcg/kg/hr sedation\n paused and pt able to nod yes/no to questions. MAE. c/o pain. Dilaudid\n 0.5mg IV PRN. Pt last received paralytic at 1630 and not reversed. Left\n PICC c/d/i. Right femoral dbl lumen CVL. Left a-line. J-tube to gravity\n w/ bilious output. Foley to gravity. Anterior neck dressing c/d/i. hard\n neck collar on at all times. Neuro checks Q4hrs. CT by morning rounds.\n Husband at BS and Dr has updated him on pt condition. Plan for\n extubation in am. Pt is stable at this time.\n" }, { "category": "General", "chartdate": "2111-01-02 00:00:00.000", "description": "Generic Note", "row_id": 609457, "text": "TITLE:\n Pt is 57y/o female s/p anterior cervical discectomies C4-5, 5-6,. C5\n Corpectomy, C6 Corpectomy, C4-7 fusion w/ allograft and plating.\n Received pt from OR intubated on Propofol gtt at 100mcg/kg/hr\n" }, { "category": "Physician ", "chartdate": "2111-01-03 00:00:00.000", "description": "Intensivist Note", "row_id": 609523, "text": "SICU\n HPI:\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n unable to asess neuro exam because she doesn't cooperate. some sort of\n munchausen's syndrome.\n Chief complaint:\n Transferred from with 6 weeks neck pain, 3 weeks increasing\n weakness. MRI there -> osteo/discitis in C5-C6. Reportedly no epidural\n abscess.\n PMHx:\n :-Perforated esophagus vs tear in and (secondary\n to emesis gastroparesis)\n -mechanical ventilation / intubation \n -MRSA bacteremia /\n -Gastroparesis (likely narcotic induced vs idiopathic): History\n of TPN, G-J tube for gastroparesis/ po intake supported by tube feeds\n -Supraclavicular clot / treated by \"balloon\"\n -Childhood constipation\n -chronic chest pain\n -History eating disorder\n -Narcotic induced ileus\n -History of laxative abuse and ? eating disorder\n -RUE DVT - line associated\n -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy\n -GERD\n -C. difficile colitis\n -Mild esophagitis\n -Cholecystitis\n -Hysterectomy for uterine cancer \n -Migraine headaches\n -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Current medications:\n . 2. 20 mEq Potassium Chloride / 1000 mL NS 3.\n Acetaminophen-Caff-Butalbital 4. Acetaminophen 5. DiCYCLOmine\n 6. Docusate Sodium (Liquid) 7. Fentanyl Patch 8. HYDROmorphone\n (Dilaudid) 9. Heparin Flush (10 units/ml)\n 10. HydrOXYzine 11. 12. Lansoprazole Oral Disintegrating Tab 13.\n Lorazepam 14. Metoclopramide 15. Methocarbamol\n 16. Multivitamins W/minerals 17. Papain 2.5 % Solution 18. Pregabalin\n 19. Promethazine 20. Scopolamine Patch\n 24 Hour Events:\n F/up CAT scan\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Infusions:\n Propofol - 90 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:45 PM\n Other medications:\n Flowsheet Data as of 01:26 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: 36.7\nC (98\n HR: 66 (66 - 94) bpm\n RR: 12 (12 - 14) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 3,035 mL\n 138 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,035 mL\n 138 mL\n Blood products:\n Total out:\n 1,520 mL\n 0 mL\n Urine:\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,515 mL\n 138 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): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SPO2: 99%\n ABG: ////\n Ve: 5.1 L/min\n Physical Examination\n General Appearance: No acute distress, neck in collar\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: ASSESSMENT:57 year old white female with extensive\n pmh including relatively recent esphageal perforation and PICC\n associated MRSA bacteremia presenting with neck pain and OSH MRI that\n shows C5-C6 osteomyelitis/discitis.s/p Anterior cervical discectomies\n C4-5, C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with\n allograft and plating ()\n plan for possible posterior fusion on depending on post op scan\n Neurologic:sedated with propofol\n Cardiovascular:stable hemodynamics.no vasopressors\n Pulmonary:CMV/AC 50 % fio2 ? extubation today\n Gastrointestinal / Abdomen:soft,J tube .Patient has h/o severe nausea\n and vomiting leading to esophageal tears.Phenargan works best for her.\n Nutrition: Vivonex TEN Full strength goal 50\n Renal:monitor UO\n Hematology:hct 32\n Endocrine:\n ID: No abx until cultures are back (no signs of infection in the OR)\n Lines / Tubes / Drains:a line/PICC/J tube/foley\n Wounds:ASPEN collar at all times\n Imaging:f/up rpt CT scan final report\n Fluids:NS + 20 k @ 75CC/HR\n Consults:neurosurgery\n Billing Diagnosis:s/p Anterior cervical discectomies C4-5, C5-6, C6-7,\n C5 corpectomy, C6 corpectomy, C4-7 fusion with allograft and plating\n Prophylaxis:\n DVT:SCD\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Lines:\n Multi Lumen - 06:28 PM\n PICC Line - 06:29 PM\n Arterial Line - 06:30 PM\n Total time spent: 32 min\n" }, { "category": "Nursing", "chartdate": "2111-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609622, "text": "Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2111-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609624, "text": "HPI:\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n Some sort of Munchausen\ns syndrome.\n Nausea / vomiting\n Assessment:\n Pt with c/o mild nausea\n Abd soft, non tender, pos bs\n Gtube to gravity, small amount of thin bilious drainage\n Jtube clamped at start of shift\n No vomiting noted\n Pt able to take pills crushed in a little applesauce as well\n as sips of Ginger ale\n No BM x5 days\n Action:\n Phenergan Q4hrs ATC\n Reglan as ordered\n TF started at 10cc/hr, increased as pt tolerates\n Senna and colace given\n Response:\n Pt stating nausea has improved\n Tol TF well\n No BM at this time\n Plan:\n Continue to increase TF to goal of 20cc/hr\n Phenergan and raglan as ordered\n Continue with bowel regimen\n Provide pt with emotional support\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt appears to be resting comfortably and dozing\n intermittently although pt c/o incisional pain, HA and\n occasional upper extremity pain\n Pt currently on Fent PCA and receiving dilaudid 1mg IVP Q1hr\n with min effect\n Pain issues discussed with MD \n Action:\n 1mg IV Dilaudid given Q1hr\n Fent PCA changed to Dilaudid PCA\n Fioricet given prn\n Response:\n Awaiting results of medication change with PCA, pt currently\n sleeping, VSS\n Plan:\n Provide pt with emotional support\n Continue with current pain regimen\n Consider pain consult\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609488, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V , extensive psych history including\n eating disorder (pt denies). Transferred from with 6 weeks\n neck pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in recent past). Afebrile\n and WBC here OK; ESR 40's. No growth on OSH blood cultures. Initially\n on Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to floor for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrographin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. . J collar in place. To OR \n to fuse and clean out her cervical spine.\n Osteomyelitis\n Assessment:\n Lightly sedated on PPF. Opens eyes spontaneously, follows\n commands.\n Intubated overnoc\n BUE\ns lift and fall back, normal strength BLE\n J collar in place\n JP draining small amts s/s drainage\n Anterior neck incision with DSD C/D/I\n G/J tube in place. G tube to gravity. J tube clogged.\n Action:\n Neuro checks q 4\n Weaning PPF\n Dilaudid prn pain\n Papain given to unclog J tube to give meds. Unable to start\n TF\ns as Vivonex not available. aware.\n Response:\n Neuro exam unchanged\n J tube patent\n Plan:\n Extubate this am\n Cont neuro checks\n Pain control\n Restart TF\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609493, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V , extensive psych history including\n eating disorder (pt denies). Transferred from with 6 weeks\n neck pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in recent past). Afebrile\n and WBC here OK; ESR 40's. No growth on OSH blood cultures. Initially\n on Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to floor for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrographin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. . J collar in place. To OR \n to fuse and clean out her cervical spine.\n Osteomyelitis\n Assessment:\n Requiring large amts of sedation. Opens eyes spontaneously,\n follows commands.\n Intubated overnoc\n BUE\ns lift and fall back, normal strength BLE\n J collar in place\n JP draining small amts s/s drainage\n Anterior neck incision with DSD C/D/I\n G/J tube in place. G tube to gravity. J tube clogged.\n Action:\n Neuro checks q 4\n Weaning PPF to off\n Dilaudid dose increased\n Papain given to unclog J tube to give meds. Unable to start\n TF\ns as Vivonex not available. aware.\n Response:\n Neuro exam unchanged\n J tube patent\n Plan:\n Extubate this am\n Cont neuro checks\n Pain control\n Restart TF\n" }, { "category": "Respiratory ", "chartdate": "2111-01-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 609494, "text": "Demographics\n Day of mechanical ventilation: 2\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\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: 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: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan is to extubate this am\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n \n No problems.\n Bedside Procedures: Patient has been transitioned to CPAP/PSV. Latest\n abg (on A/C and 50%) revealed a normal acid-base balance with excellent\n oxygenation.\n RSBI = 46 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609495, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V , extensive psych history including\n eating disorder (pt denies). Transferred from with 6 weeks\n neck pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in recent past). Afebrile\n and WBC here OK; ESR 40's. No growth on OSH blood cultures. Initially\n on Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to floor for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrographin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. . J collar in place. To OR \n to fuse and clean out her cervical spine.\n Osteomyelitis\n Assessment:\n Requiring large amts of sedation. Opens eyes spontaneously,\n follows commands.\n Intubated overnoc\n BUE\ns lift and fall back, normal strength BLE\n J collar in place\n JP draining small amts s/s drainage\n Anterior neck incision with DSD C/D/I\n G/J tube in place. G tube to gravity. J tube clogged.\n Action:\n Neuro checks q 4\n Post op CT of C-spine done\n Weaning PPF to off\n Dilaudid dose increased\n Papain given to unclog J tube to give meds. Unable to start\n TF\ns as Vivonex not available. aware.\n Response:\n Neuro exam unchanged\n J tube patent\n Plan:\n Extubate this am\n Cont neuro checks\n Pain control\n Restart TF\n" }, { "category": "Physician ", "chartdate": "2111-01-04 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 609668, "text": "24 Hour Events:\n SPUTUM CULTURE - At 10:12 AM\n BLOOD CULTURED - At 10:42 AM\n URINE CULTURE - At 10:42 AM\n INVASIVE VENTILATION - STOP 11:00 AM\n EKG - At 06:59 AM\n FEVER - 102.0\nF - 06:00 AM\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to medicine initially for med clearance prior to\n Nsurg intervention, esp with regard to esophagus --BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n Went to OR with nsurg to fuse and clean out her cervical spine.\n Yesterday, pt extubated. Tube feeds started. Spiked fever. Per ID, Vanc\n started.\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 02:00 PM\n Lorazepam (Ativan) - 04:00 AM\n Hydromorphone (Dilaudid) - 05:57 AM\n Other medications:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.4\nC (101.1\n HR: 117 (96 - 120) bpm\n BP: 103/55(70) {103/55(70) - 159/88(115)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 2,525 mL\n 1,079 mL\n PO:\n 30 mL\n 60 mL\n TF:\n 35 mL\n 94 mL\n IVF:\n 2,310 mL\n 925 mL\n Blood products:\n Total out:\n 2,840 mL\n 720 mL\n Urine:\n 2,800 mL\n 720 mL\n NG:\n Stool:\n Drains:\n 40 mL\n Balance:\n -315 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 472 (472 - 472) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: 7.48/37/94./26/3\n Ve: 7.1 L/min\n PaO2 / FiO2: 235\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: S3, S4\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\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 234 K/uL\n 9.1 g/dL\n 100 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 107 mEq/L\n 139 mEq/L\n 27.6 %\n 7.3 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 02:51 AM\n 03:15 AM\n WBC\n 5.2\n 7.3\n Hct\n 29.5\n 27.6\n Plt\n 269\n 234\n Cr\n 0.4\n 0.4\n TCO2\n 27\n 28\n Glucose\n 111\n 100\n Other labs: PT / PTT / INR:12.5/25.8/1.1, ALT / AST:16/21, Alk Phos / T\n Bili:172/0.4, Albumin:3.0 g/dL, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O EATING DISORDER (INCLUDING ANOREXIA NERVOSA, BULEMIA), NAUSEA /\n VOMITING, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), OSTEOMYELITIS\n 57 year old female with extensive pmh including relatively recent\n esphageal perforation and PICC associated MRSA bacteremia presenting\n with neck pain and OSH MRI that showed C5-C6 osteomyelitis/discitis now\n s/p Anterior cervical discectomies C4-5, C5-6, C6-7, C5 corpectomy, C6\n corpectomy, C4-7 fusion with allograft and plating (). Possible\n plan for posterior fusion on .\n Neurologic: AOx4. Pain controlled on dilaudid PCA + prn dilaudid IV for\n breakthrough. Also on fioricet, methocarbamol, lyrica, and fentanyl\n patch. Pt possibly returning to OR for posterior cervical fusion.\n Cardiovascular: stable hemodynamics. no vasopressors\n Pulmonary: Extubated . Satting high 90's on 2L NC.\n Gastrointestinal/Abdomen: G-J tube. Patient has h/o severe nausea and\n vomiting leading to esophageal tears. Nausea adequately controlled on\n phenergan, reglan, scopolamine. (Per pt, phenergan works best for her).\n Nutrition: Vivonex TEN Full strength goal 20ml/hr. (20ml/hr is pt's\n home rate). Clears and applesauce PO.\n Renal: monitor UOP. Cr WNL.\n Hematology: hct stable\n Endocrine: Consider ISS.\n ID: Osteomyelitis/Coag positive Staph Aureus on surgical tissue cx.\n Febrile. Follow up BCX/UCX/Sputum CX. Vancomycin started 12/13 per ID\n recs.\n Lines / Tubes / Drains:Right femoral TLC, L arm PICC. A-line, Foley.\n Wounds: ASPEN collar at all times\n Imaging: f/u rpt CT scan final report\n Fluids:NS + 20 k @ 75CC/HR\n Consults: Neurosurgery\n Billing Diagnosis: Osteomyelitis; s/p Anterior cervical discectomies\n C4-5, C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with\n allograft and plating\n Prophylaxis:\n DVT: SCD\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU\n ICU Care\n Nutrition:\n Vivonex (Full) - 08:30 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 06:28 PM\n PICC Line - 06:29 PM\n Arterial Line - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2111-01-04 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 609671, "text": "24 Hour Events:\n SPUTUM CULTURE - At 10:12 AM\n BLOOD CULTURED - At 10:42 AM\n URINE CULTURE - At 10:42 AM\n INVASIVE VENTILATION - STOP 11:00 AM\n EKG - At 06:59 AM\n FEVER - 102.0\nF - 06:00 AM\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to medicine initially for med clearance prior to\n Nsurg intervention, esp with regard to esophagus --BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n Went to OR with nsurg to fuse and clean out her cervical spine.\n Yesterday, pt extubated. Tube feeds started. Spiked fever. Per ID, Vanc\n started.\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 02:00 PM\n Lorazepam (Ativan) - 04:00 AM\n Hydromorphone (Dilaudid) - 05:57 AM\n Other medications:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.4\nC (101.1\n HR: 117 (96 - 120) bpm\n BP: 103/55(70) {103/55(70) - 159/88(115)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 2,525 mL\n 1,079 mL\n PO:\n 30 mL\n 60 mL\n TF:\n 35 mL\n 94 mL\n IVF:\n 2,310 mL\n 925 mL\n Blood products:\n Total out:\n 2,840 mL\n 720 mL\n Urine:\n 2,800 mL\n 720 mL\n NG:\n Stool:\n Drains:\n 40 mL\n Balance:\n -315 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 472 (472 - 472) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: 7.48/37/94./26/3\n Ve: 7.1 L/min\n PaO2 / FiO2: 235\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: S3, S4\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\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 234 K/uL\n 9.1 g/dL\n 100 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 6 mg/dL\n 107 mEq/L\n 139 mEq/L\n 27.6 %\n 7.3 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 02:51 AM\n 03:15 AM\n WBC\n 5.2\n 7.3\n Hct\n 29.5\n 27.6\n Plt\n 269\n 234\n Cr\n 0.4\n 0.4\n TCO2\n 27\n 28\n Glucose\n 111\n 100\n Other labs: PT / PTT / INR:12.5/25.8/1.1, ALT / AST:16/21, Alk Phos / T\n Bili:172/0.4, Albumin:3.0 g/dL, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O EATING DISORDER (INCLUDING ANOREXIA NERVOSA, BULEMIA), NAUSEA /\n VOMITING, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), OSTEOMYELITIS\n 57 year old female with extensive pmh including relatively recent\n esphageal perforation and PICC associated MRSA bacteremia presenting\n with neck pain and OSH MRI that showed C5-C6 osteomyelitis/discitis now\n s/p Anterior cervical discectomies C4-5, C5-6, C6-7, C5 corpectomy, C6\n corpectomy, C4-7 fusion with allograft and plating (). Possible\n plan for posterior fusion on .\n Neurologic: AOx4. Pain controlled on dilaudid PCA + prn dilaudid IV for\n breakthrough. Also on fioricet, methocarbamol, lyrica, and fentanyl\n patch. Pt possibly returning to OR for posterior cervical fusion.\n Cardiovascular: stable hemodynamics. no vasopressors\n Pulmonary: Extubated . Satting high 90's on 2L NC.\n Gastrointestinal/Abdomen: G-J tube. Patient has h/o severe nausea and\n vomiting leading to esophageal tears. Nausea adequately controlled on\n phenergan, reglan, scopolamine. (Per pt, phenergan works best for her).\n Nutrition: Vivonex TEN Full strength goal 20ml/hr. (20ml/hr is pt's\n home rate). Clears and applesauce PO.\n Renal: monitor UOP. Cr WNL.\n Hematology: hct stable\n Endocrine: Consider ISS.\n ID: Osteomyelitis/Coag positive Staph Aureus on surgical tissue cx.\n Febrile. Follow up BCX/UCX/Sputum CX. Vancomycin started 12/13 per ID\n recs.\n Lines / Tubes / Drains:Right femoral TLC, L arm PICC. A-line, Foley.\n Wounds: ASPEN collar at all times\n Imaging: f/u rpt CT scan final report\n Fluids:NS + 20 k @ 75CC/HR\n Consults: Neurosurgery\n Billing Diagnosis: Osteomyelitis; s/p Anterior cervical discectomies\n C4-5, C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with\n allograft and plating\n Prophylaxis:\n DVT: SCD\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU\n ICU Care\n Nutrition:\n Vivonex (Full) - 08:30 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 06:28 PM\n PICC Line - 06:29 PM\n Arterial Line - 06:30 PM\n Code status:\n Disposition:\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609485, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n unable to asess neuro exam because she doesn't cooperate. some sort of\n munchausen's syndrome.\n" }, { "category": "Nursing", "chartdate": "2111-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609486, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V , extensive psych history including\n eating disorder (pt denies). Transferred from with 6 weeks\n neck pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in recent past). Afebrile\n and WBC here OK; ESR 40's. No growth on OSH blood cultures. Initially\n on Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to floor for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrographin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. . J collar in place. To OR \n to fuse and clean out her cervical spine.\n" }, { "category": "Respiratory ", "chartdate": "2111-01-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 609584, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\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 / Small\n Comments: Pt extubated to 50% cool aerosol with spo2 upper 90s and good\n cuff leak noted. Will cont to follow as needed.\n" }, { "category": "Nursing", "chartdate": "2111-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609649, "text": "HPI:\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n Some sort of Munchausen\ns syndrome.\n Nausea / vomiting\n Assessment:\n Pt with c/o mild nausea\n Abd soft, non tender, pos bs\n Gtube to gravity, small amount of thin bilious drainage\n Jtube clamped at start of shift\n No vomiting noted\n Pt able to take pills crushed in a little applesauce as well\n as sips of Ginger ale\n No BM x5 days\n Action:\n Phenergan Q4hrs ATC\n Reglan as ordered\n TF started at 10cc/hr, increased as pt tolerates\n Senna and colace given\n Response:\n Pt stating nausea has improved\n Tol TF well\n No BM at this time\n Plan:\n Continue to increase TF to goal of 20cc/hr\n Phenergan and raglan as ordered\n Continue with bowel regimen\n Provide pt with emotional support\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt appears to be resting comfortably and dozing\n intermittently although pt c/o incisional pain, HA and\n occasional upper extremity pain\n Pt currently on Fent PCA and receiving dilaudid 1mg IVP Q1hr\n with min effect\n Pain issues discussed with MD \n Action:\n 1mg IV Dilaudid given Q1hr\n Fent PCA changed to Dilaudid PCA\n Fioricet given prn\n Response:\n Awaiting results of medication change with PCA, pt currently\n sleeping, VSS\n Plan:\n Provide pt with emotional support\n Continue with current pain regimen\n Consider pain consult\n ------ Protected Section ------\n Pt became tachy to 120\ns and slightly hypertensive to 160\ns b/w 0530\n and 0600, temp taken as pt stating she is cold, temp 102. MD \n notified. Fioricet given per pt request, declined regular Tylenol. Pt\n also refusing to have the blankets removed. No cultures drawn, pt\n already cultured on . Pt also c/o increased ABD pain since TF have\n been increased, TF rate decreased to 10cc/hr. ABD softly distended,\n tender to touch. Denies nausea.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:04 ------\n Also spoke with pt about pt\ns baseline pain, pt states that she is \n at home. She does state that the pain is worse than at home but still\n rates her pain as a \n ------ Protected Section Addendum Entered By: , RN\n on: 06:21 ------\n" }, { "category": "Nursing", "chartdate": "2111-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609775, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n Some sort of Munchausen\ns syndrome\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with acute and chronic pain, very demanding of pain medications most\n of the time, rates pain at .\n Action:\n Medicated with Dilauded PCA, Dilauded IV push, Ativan, Fioricet and\n Fentanyl patch.\n Trazadone given late evening.\n Response:\n Pt able to sleep for periods overnight, especially when given full 2mg\n dose of Dilauded IV. Using PCA a lot when awake, and requesting\n dialuded Q1-2hrs aswell.\n Plan:\n Continue to medicate as needed for pain.\n" }, { "category": "Nursing", "chartdate": "2111-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609645, "text": "HPI:\n 57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n Some sort of Munchausen\ns syndrome.\n Nausea / vomiting\n Assessment:\n Pt with c/o mild nausea\n Abd soft, non tender, pos bs\n Gtube to gravity, small amount of thin bilious drainage\n Jtube clamped at start of shift\n No vomiting noted\n Pt able to take pills crushed in a little applesauce as well\n as sips of Ginger ale\n No BM x5 days\n Action:\n Phenergan Q4hrs ATC\n Reglan as ordered\n TF started at 10cc/hr, increased as pt tolerates\n Senna and colace given\n Response:\n Pt stating nausea has improved\n Tol TF well\n No BM at this time\n Plan:\n Continue to increase TF to goal of 20cc/hr\n Phenergan and raglan as ordered\n Continue with bowel regimen\n Provide pt with emotional support\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt appears to be resting comfortably and dozing\n intermittently although pt c/o incisional pain, HA and\n occasional upper extremity pain\n Pt currently on Fent PCA and receiving dilaudid 1mg IVP Q1hr\n with min effect\n Pain issues discussed with MD \n Action:\n 1mg IV Dilaudid given Q1hr\n Fent PCA changed to Dilaudid PCA\n Fioricet given prn\n Response:\n Awaiting results of medication change with PCA, pt currently\n sleeping, VSS\n Plan:\n Provide pt with emotional support\n Continue with current pain regimen\n Consider pain consult\n ------ Protected Section ------\n Pt became tachy to 120\ns and slightly hypertensive to 160\ns b/w 0530\n and 0600, temp taken as pt stating she is cold, temp 102. MD \n notified. Fioricet given per pt request, declined regular Tylenol. Pt\n also refusing to have the blankets removed. No cultures drawn, pt\n already cultured on . Pt also c/o increased ABD pain since TF have\n been increased, TF rate decreased to 10cc/hr. ABD softly distended,\n tender to touch. Denies nausea.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:04 ------\n" }, { "category": "Nursing", "chartdate": "2111-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609742, "text": "57F with h/o gastroparesis (chronic J tube with TF's), esophageal tear\n from chronic abd pain/N/V . Transferred from with 6\n weeks neck pain, 3 weeks increasing weakness. MRI there ->\n osteo/discitis in C5-C6. Reportedly no epidural abscess. Got\n vanc/ceftaz at . H/o multiple line infections (including MRSA\n in recent past). Afebrile and WBC here OK; ESR 40's. No growth on OSH\n blood cultures to date, ours pending/NGTD so far as well. Initially on\n Vanco here, but ID rec d/c and watch cx data, temp, WBC until \n intervention. Admitted to us for med clearance prior to Nsurg\n intervention, esp with regard to esophagus -- BAS/UGI with\n gastrograffin on neg for evidence of perf. Also with some R hand\n swelling, but LENI neg for clot. has PICC for access, since poor\n peripherals and IV nurse unable to get on floor. Hard collar in place.\n went to OR with nsurg to fuse and clean out her cervical spine.\n Some sort of Munchausen\ns syndrome.\n Osteomyelitis\n Assessment:\n Chronic and acute pain in abdomen, neck, back, arms, and h/a. Pt on\n multiple meds at home prior to admit. Has a G tube to gravity and J\n tube to tube feeds currently infusing at 10/hr d/ tunable to tolerate.\n C/o mild nausea this morning and consistently rates her pain 10 + on\n scale 0-10. Stated that following her supplemental dilaudid doses she\n occasionally can rate her pain an 8 at the lowest. Pt able to carry\n conversations and is pleasant and cooperative. Able to dose off for\n 30-1 hour at a time and then wakes up stating she is in pain d/t\n falling asleep and not hitting the pca button.\n Action:\n Medicated with dilaudid 1mg iv q 1 hour plus increased pca dose to\n 0.37. Pain services consulted and in to meet pt this afternoon. Pt also\n receives ativan iv 1 mg q 4-6 hours, phenergen, fioricet, and\n metacarbamol. Fent patch in place. Pt encourated to cough and deep\n breathe and to use incentive spirometer. Pt did not want to get oob but\n ok given by MD and pt was persuaded to dangle at the side of the\n bed and later assisted to the commode. Fent patch changed and dose\n increased.\n Response:\n Did not tolerate oob well with drop in o2 sat, dizziness, and pain. Pt\n unable to have a bowel movement and given lactulose via jtube. No\n results yet. Pain still rated at 10 but have been given 0.5 mg ivp\n instead of 1 mg to supplement pca and pt has not c/o of any increased\n pain. Sats at times borderline 91-93 on nasal cannula and encouraged\n to cough and deep breathe/ use IS with some improvement to 94-97%.\n Plan:\n Cont to encourage coughing and deep breathing/ oob. Needs PT? J\n collar to remain in place ?x 6 weeks. Cont ivf until pt is taking\n enough pos. Tube feeds increased toward goal tomorrow if tolerated.\n Cont with pain medication weaning as able per pain service. Psych\n involvement?\n" }, { "category": "Nutrition", "chartdate": "2111-01-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 609844, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 160 cm\n 43.09 kg\n 55.6 kg ( 06:00 PM)\n Pertinent medications: ativan, dilaudid, RISS, Colace, senna,\n multivitamin with minerals, reglan, abx, heparin, lactulose, Kcl\n repletion, others noted\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 02:28 AM\n Glucose Finger Stick\n 155\n 10:00 AM\n BUN\n 7 mg/dL\n 02:28 AM\n Creatinine\n 0.5 mg/dL\n 02:28 AM\n Sodium\n 142 mEq/L\n 02:28 AM\n Potassium\n 3.3 mEq/L\n 02:28 AM\n Chloride\n 110 mEq/L\n 02:28 AM\n TCO2\n 25 mEq/L\n 02:28 AM\n PO2 (arterial)\n 94. mm Hg\n 03:15 AM\n PCO2 (arterial)\n 37 mm Hg\n 03:15 AM\n pH (arterial)\n 7.48 units\n 03:15 AM\n pH (urine)\n 5.0 units\n 08:57 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 03:15 AM\n Albumin\n 3.0 g/dL\n 02:51 AM\n Calcium non-ionized\n 8.1 mg/dL\n 02:28 AM\n Phosphorus\n 3.2 mg/dL\n 02:28 AM\n Magnesium\n 2.1 mg/dL\n 02:28 AM\n ALT\n 14 IU/L\n 02:28 AM\n Alkaline Phosphate\n 192 IU/L\n 02:28 AM\n AST\n 15 IU/L\n 02:28 AM\n Total Bilirubin\n 0.4 mg/dL\n 02:28 AM\n WBC\n 7.6 K/uL\n 02:28 AM\n Hgb\n 8.2 g/dL\n 02:28 AM\n Hematocrit\n 25.1 %\n 02:28 AM\n Current diet order / nutrition support: Tube Feeds: Vivonex @ 20mL/hr\n (480kcals, 18g protein)\n GI: abd soft, distended, + bowel sounds\n Assessment of Nutritional Status\n 57 year old female with extensive pmh including relatively recent\n esphageal perforation and PICC associated MRSA/MSSA bacteremia\n presenting with neck pain and OSH MRI that showed C5-C6\n osteomyelitis/discitis. Patient now s/p Anterior cervical discectomies\n C4-5, C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with\n allograft and plating (). Patient is currently receiving tube\n feeds\n Vivonex @ 20mL/hr, which meets about 40% of calorie needs.\n Paitent is also taking small amounts of clear liquids as she\n tolerates. Recommend increasing tube feeds slowly to goal of 50mL/hr\n to meet her calorie and protein needs. Continue with bowel regimen and\n lyte repletions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Increase tube feeds to VIvonex @ 50mL/hr (1200kcals, 46g\n protein).\n Monitor lytes and hydration.\n Diet as tolerated.\n Following -#\n" }, { "category": "Nursing", "chartdate": "2111-01-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 609845, "text": "57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis/discitis (MRSA.)\n PMHx:\n Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. reporting high levels of pain from . Pt. vitals are\n stable/at baseline and she is noted to reach for items at bedside and\n move freely in bed when alone in room.\n Action:\n Pt. receiving 1-2mg IV dilaudid Q1-2 hrs as documented, utilizing\n dilaudid PCA. Pt. also receiving fioricet Q6hrs, ativan Q4hrs, and\n muscle relaxors ATC.\n Response:\n Lowest pain level thus far today . Pt. states an acceptable level\n for her is . ?Reliabilty of subjective information.\n Plan:\n Medicated pre CPS rec\ns. Monitor and treat as indicated.\n Osteomyelitis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2111-01-06 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 609903, "text": "HPI:\n 57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis.\n 24 Hour Events:\n FEVER - 102.5\nF - 05:00 PM\n Allergies:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Last dose of Antibiotics:\n Vancomycin - 08:20 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 PM\n Hydromorphone (Dilaudid) - 12:29 AM\n Heparin Sodium (Prophylaxis) - 12:34 AM\n Other medications:\n Flowsheet Data as of 12:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.5\n Tcurrent: 36.4\nC (97.6\n HR: 93 (82 - 130) bpm\n BP: 105/62(79) {81/45(60) - 162/93(116)} mmHg\n RR: 10 (10 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 55.6 kg\n Total In:\n 3,282 mL\n 137 mL\n PO:\n 270 mL\n 60 mL\n TF:\n 484 mL\n 31 mL\n IVF:\n 2,248 mL\n 46 mL\n Blood products:\n Total out:\n 2,860 mL\n 220 mL\n Urine:\n 2,860 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 422 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\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: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 119 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 110 mEq/L\n 142 mEq/L\n 25.1 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 02:51 AM\n 03:15 AM\n 02:28 AM\n WBC\n 5.2\n 7.3\n 7.6\n Hct\n 29.5\n 27.6\n 25.1\n Plt\n \n Cr\n 0.4\n 0.4\n 0.5\n TCO2\n 27\n 28\n Glucose\n 111\n 100\n 119\n Other labs: PT / PTT / INR:13.8/33.5/1.2, ALT / AST:14/15, Alk Phos / T\n Bili:192/0.4, Albumin:3.0 g/dL, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O EATING DISORDER (INCLUDING ANOREXIA NERVOSA, BULEMIA), NAUSEA /\n VOMITING, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), OSTEOMYELITIS\n ASSESSMENT:57 year old female with extensive pmh including relatively\n recent esphageal perforation and PICC associated MRSA/MSSA bacteremia\n presenting with neck pain and OSH MRI that showed C5-C6\n osteomyelitis/discitis now s/p Anterior cervical discectomies C4-5,\n C5-6, C6-7, C5 corpectomy, C6 corpectomy, C4-7 fusion with allograft\n and plating ().\n Neurologic: Chronic pain issues. Anxiety. Somatoform disorder. Chronic\n pain consulted. Pain controlled on dilaudid PCA. Req iv dilaudid for\n btp. On fioricet, methocarbamol, lyrica, and fentanyl patch. Ativan and\n trazodone for anxiety. Neuro checks q4hr. ? psych consult for\n somoatoform dis\n Cardiovascular: Tachy. Baseline hypotension. SBP<160 stable\n hemodynamics. no vasopressors, allow autoregulation\n Pulmonary: Extubated . Stable on NC\n Gastrointestinal/Abdomen: Gastroparesis s/p G-J tube. H/o eating\n disorder and tears from vomiting. Nausea adequately\n controlled on phenergan, reglan, scopolamine. Full bowel regimen\n Nutrition: Vivonex TEN Full strength goal 20ml/hr. (20ml/hr is pt's\n home rate)increased goal to 50 as per dietician. Clears diet.\n Renal: monitor UOP. Cr WNL.\n Hematology: hct stable 25.1. On SQH\n Endocrine: RISS\n ID: Osteomyelitis - MRSA on surgical tissue cx. Febrile. Follow up\n BCX/UCX/Sputum CX. Vancomycin. Follow troughs. ID following.still\n spikes fever. Consider dc fem line, dc picc - resite\n Lines / Tubes / Drains: R femoral TLC, L arm PICC. A-line, Foley. new\n picc pending\n Wounds: ASPEN collar at all times\n Imaging:\n Fluids: KVO\n Consults: Neurosurgery\n Billing Diagnosis: Osteomyelitis; gastroparesis, chronic pain\n Prophylaxis:\n DVT: SCD, SQH\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU-step down\n Nutrition:\n Vivonex (Full) - 02:56 PM 50 mL/hour\n PICC Line - 06:29 PM\n Arterial Line - 06:30 PM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610005, "text": "Osteomyelitis\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610012, "text": "Osteomyelitis\n Assessment:\n Afebrile. A&O x3. Able to lift and hold all extremities. LCTA\n diminished at bases. On 2L O2 via NC. Using IS with good technique.\n Action:\n Neuro checks q4 hours. Antibiotics as ordered\n vanco dose increased.\n Encouraged C&DB. OOB to chair. ID spoke with family regarding\n medication regimen.\n Response:\n Pt stable.\n Plan:\n Continue to follow temperature curve. Pulmonary hygiene. Check vanco\n trough in am. Transfer to SDU when bed available.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting constant pain at rest. Pain in neck, back and both\n arms. Able to brush hair, wash face and brush teeth with assist for\n set-up only.\n Action:\n Receiving 2mg dilaudid q2 hours as ordered. Using Dilaudid PCA\n appropriately. Fentanyl patch on as ordered. Receiving muscle\n relaxant and Lyrica as ordered. Repositioned in bed q 2 hours.\n Provided emotional support.\n Response:\n Pt noted to be dozing in bed/chair after pain medication\n administration, though per pt in constant pain.\n Plan:\n Continue to follow chronic pain recommendations. Emotional support.\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610079, "text": "57 year old female with history of esophageal tear initially at GE\n junction , hospital course complicated by MSSA bacteremia. More\n recently admitted with repeat esophageal perforation in cervical region\n of esophagus in . During that hospitalization, she was\n treated broadly with vanco/gent then Ertapenem. She was discharged from\n , unclear if on or off antibiotics.\n : She was admitted as a transfer from with 6 weeks neck\n pain, 3 weeks increasing weakness. MRI there -> osteo/discitis in\n C5-C6. Reportedly no epidural abscess. Got vanc/ceftaz at .\n H/o multiple line infections (including MRSA in past). Afebrile. No\n growth on OSH blood cultures. OR with nsurg to fuse and clean out\n her cervical spine. Now s/p C5 and 6 corpectomies allograft/plate for\n osteomyelitis/discitis (MRSA.)\n PMHx:\n Perforated esophagus vs tear in and (secondary to\n emesis gastroparesis) -mechanical ventilation / intubation \n -MRSA bacteremia / -Gastroparesis (likely narcotic\n induced vs idiopathic): History of TPN, G-J tube for gastroparesis/ po\n intake supported by tube feeds -Supraclavicular clot /\n treated by \"balloon\" -Childhood constipation -chronic chest pain\n -History eating disorder -Narcotic induced ileus -History of laxative\n abuse and ? eating disorder -RUE DVT - line associated -Chronic pain\n -History meningioma - pt to see skull based surgeon at \n -Peripheral neuropathy -GERD -C. difficile colitis -Mild\n esophagitis -Cholecystitis -Hysterectomy for uterine cancer \n -Migraine headaches -Staph aureus bacteremia in setting of TPN\n -eating disorder/laxative abuse (pt denies)\n Osteomyelitis\n Assessment:\n Afebrile. A&O x3. Able to lift and hold all extremities. LSCTA\n diminished at bases. On 2L O2 via NC. Using IS with good technique.\n Action:\n Neuro checks q4 hours. Antibiotics as ordered\n vanco dose increased.\n Encouraged C&DB. OOB to chair. ID spoke with family regarding\n medication regimen.\n Response:\n Pt stable.\n Plan:\n Continue to follow temperature curve. Pulmonary hygiene. Check vanco\n trough when ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting constant pain at rest. Pain in neck, back and both\n arms. Able to brush hair, wash face and brush teeth with assist for\n set-up only.\n Action:\n Using Dilaudid PCA appropriately. Receiving 2mg dilaudid prn for\n breakthrough pain. Fentanyl patch on as ordered. Receiving muscle\n relaxant and Lyrica as ordered. Repositioned in bed q 2 hours.\n Provided emotional support. OOB to BSC for BM x4 today post aggressive\n bowel regime\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n OSTEOMYELITIS C5,C6\n Code status:\n Height:\n Admission weight:\n 55.6 kg\n Daily weight:\n 55.6 kg\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Ciprofloxacin\n tachycardia\n \"s\n Morphine\n \"rash\n limbs sw\n Precautions:\n PMH:\n CV-PMH:\n Additional history: perofrated esophagus vs tear in and\n (secondary to emesisi gastoropariesis, G-J tube for\n gastroparsis/po intake and supported by tubefeeds, mechanial\n ventilation/ intubation ,MRSA /, eating\n disorder(pt denies), ileus, supraclavicular clot /treated by\n \"balloon\", chronic pain, perphial neuropathy, meningioma-pt to see\n skull based surgeon at , cdiff colitis, mild esophagitis, coffee\n ground emesis, cholecystitis , hysterectomy for uterine cancer\n , migranes\n Surgery / Procedure and date: anterior cervical discectomies, C4-5,\n C5-6, C6-7, C5 corpectomy, C4-7 fusion with allograft and plating\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:66\n Temperature:\n 97.6\n Arterial BP:\n S:125\n D:65\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 105 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 3,826 mL\n 24h total out:\n 3,900 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:26 AM\n Potassium:\n 3.7 mEq/L\n 02:26 AM\n Chloride:\n 106 mEq/L\n 02:26 AM\n CO2:\n 28 mEq/L\n 02:26 AM\n BUN:\n 6 mg/dL\n 02:26 AM\n Creatinine:\n 0.4 mg/dL\n 02:26 AM\n Glucose:\n 123 mg/dL\n 02:26 AM\n Hematocrit:\n 26.0 %\n 02:26 AM\n Finger Stick Glucose:\n 137\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu b\n Transferred to: 11\n Date & time of Transfer: 2200\n Response:\n Pt noted to be dozing in bed/chair after pain medication\n administration, though per pt in constant pain.\n Plan:\n Continue to follow chronic pain recommendations. Emotional support.\n" }, { "category": "Nursing", "chartdate": "2111-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610075, "text": "Osteomyelitis\n Assessment:\n Afebrile. A&O x3. Able to lift and hold all extremities. LCTA\n diminished at bases. On 2L O2 via NC. Using IS with good technique.\n Action:\n Neuro checks q4 hours. Antibiotics as ordered\n vanco dose increased.\n Encouraged C&DB. OOB to chair. ID spoke with family regarding\n medication regimen.\n Response:\n Pt stable.\n Plan:\n Continue to follow temperature curve. Pulmonary hygiene. Check vanco\n trough in am. Transfer to SDU when bed available.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting constant pain at rest. Pain in neck, back and both\n arms. Able to brush hair, wash face and brush teeth with assist for\n set-up only.\n Action:\n Receiving 2mg dilaudid q2 hours as ordered. Using Dilaudid PCA\n appropriately. Fentanyl patch on as ordered. Receiving muscle\n relaxant and Lyrica as ordered. Repositioned in bed q 2 hours.\n Provided emotional support.\n Response:\n Pt noted to be dozing in bed/chair after pain medication\n administration, though per pt in constant pain.\n Plan:\n Continue to follow chronic pain recommendations. Emotional support.\n" }, { "category": "ECG", "chartdate": "2111-01-10 00:00:00.000", "description": "Report", "row_id": 182164, "text": "Sinus rhythm. Tracing is within normal limits. Compared to the previous tracing\nof cardiac rhythm is now regular. Prior tracing may have been sinus\narrhythmia and not atrial fibrillation.\n\n" }, { "category": "ECG", "chartdate": "2111-01-05 00:00:00.000", "description": "Report", "row_id": 182165, "text": "Atrial fibrillation. Leftward axis at minus 41 degrees. Q waves in\nleads II, III, aVF and V3-V6. These changes are consistent with extensive\nmyocardial infarctions involving the inferior and anterolateral walls. Compared\nto the previous tracing of the Q waves in leads II, III, aVF and V4-V6\nare all new. Consider extensive myocardial infarctions of indeterminate age.\n\n" }, { "category": "ECG", "chartdate": "2111-01-04 00:00:00.000", "description": "Report", "row_id": 182166, "text": "Sinus tachycardia, rate 118. Early transition. Compared to the previous tracing\nof there is no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2110-12-30 00:00:00.000", "description": "Report", "row_id": 182167, "text": "Sinus tachycardia, rate 99. Compared to tracing #1 there is no diagnostic\ninterim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2110-12-30 00:00:00.000", "description": "Report", "row_id": 182168, "text": "Sinus tachycardia, rate 99. Leftward axis at 0 degrees. RSR' pattern in lead V1\nwith QRS duration of 88 milliseconds. Compared to the previous tracing\nof the flat ST segment depression, seen at that time in II, III, aVF\nand V3-V6 are no longer present. Otherwise, no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2110-12-31 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1111430, "text": " 10:18 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: OSTEOMYELITIS C5,C6\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with no access per IV team, need access for IV\n antibiotics/labs\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n\n PICC PLACEMENT\n\n INDICATION: PICC placement requested for prolonged IV antibiotics.\n\n RADIOLOGIST: Dr. , Dr. , and Dr. , the\n attending radiologist who supervised the entire procedure.\n\n TECHNIQUE: The procedure was explained to the patient. A pre-procedural\n timeout was performed, confirming the patient's identity using 3 patient\n identifiers, as well as the procedure to be performed.\n\n Using sterile technique and 1% lidocaine buffered with bicarbonate solution\n for local anesthesia, the left brachial vein was punctured under direct\n ultrasound guidance using a micropuncture set. Hard copies of ultrasound\n images were obtained before and after establishing intravenous access. A\n peel-away sheath was then placed over a guidewire and a 4 French single-lumen\n PICC line measuring 39 cm in length was then placed through the peel-away\n sheath under fluoroscopic guidance, with its tip positioned in the low SVC.\n Position of the catheter was confirmed by a final fluoroscopic spot image of\n the chest. The peel-away sheath and guidewire were then removed. The catheter\n was secured to the skin using a StatLock, the lumen aspirated, flushed and\n capped, and a sterile dressing applied.\n\n The patient tolerated the procedure well, without immediate complication.\n\n IMPRESSIONS: Uncomplicated ultrasound and fluoroscopically guided placement\n of 4-French single-lumen PICC via the left brachial venous approach. Final\n internal length is 39 cm, with the tip positioned in low SVC. The line is\n ready for use.\n\n" } ]

[ { "category": "Echo", "chartdate": "2154-10-17 00:00:00.000", "description": "Report", "row_id": 78583, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Pre-op cabg\nHeight: (in) 65\nWeight (lb): 160\nBSA (m2): 1.80 m2\nBP (mm Hg): 175/50\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 13:37\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.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.] Normal LV inflow pattern\nfor age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect is seen by 2D\nor color Doppler. There is mild symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF 70%). No masses or thrombi are seen in the left\nventricle. There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing,\nthe severity of mitral regurgitation may be significantly UNDERestimated.]\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2154-10-18 00:00:00.000", "description": "Report", "row_id": 182317, "text": "Sinus bradycardia\nRight bundle branch block\nProbable old inferior infarct\nNonspecific T wave changes\nSince previous tracing, decreased QRS voltages\n\n" }, { "category": "ECG", "chartdate": "2154-10-17 00:00:00.000", "description": "Report", "row_id": 182318, "text": "Sinus bradycardia\nLeft axis deviation\nRBBB with left anterior fascicular block\nProbable old inferior infarct\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2154-10-19 00:00:00.000", "description": "Report", "row_id": 182315, "text": "Sinus rhythm. No significant change compared to the previous tracing\nof .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2154-10-18 00:00:00.000", "description": "Report", "row_id": 182316, "text": "Sinus rhythm. No significant change compared to the previous tracing\nof .\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2154-10-18 00:00:00.000", "description": "Report", "row_id": 1501851, "text": "PT ARRIVED FROM OR S/P CABG X2 (LIMA->LAD, SVG-> DIAG) PT ARRIVED ON PROP, HR 45-61. PT ONLY V WIRES AND BP NO TOLERATE. PT GIVEN 750 LR WITH GOOD CI> 2.6. SVO2 74. SBP 130-150. STABLE. PT DIFFICULT FOLEY PLACEMENT IN OR UROLOGY CALLED TO PLACE UNDER CYSTOSCOPY NOW WITH LG AMT HEMATURIA REQUIRING FREQUENT IRRIGATION. PT NOT REVERSED BUT AWOKE AND MAE AND NODDED HEAD TO QUESTIONS. PT TO CATH LAB FOR PLANNED STENT OF LM AND L CIRC AT 1400 (SUCCESSFUL). IN CATH LAB PT WITH LABILE BP REQUIRING NEO AND IVF. PT RECIEVED TOTAL APPROX 1L IVF AND 300 IV DYE. PT GIVEN ASA 325MG AND PLAVIX 300MG PRIOR TO CATH. PT ALSO GIVEN UNITS HEPARIN IN LAB TO ACHIEVE ACT>200. LAST ACT LEAVING CATH LAB 212. PT HAD RT FEM ARTERIAL SHEATH PLACED. ALSO NOTED TO HAVE NEW INTERMITTENT SMALL LEAK IN CT IN LAB. UPON RETURN TO CSRU AT 1800 PT NOTED TO HAVE LG AMT SANG DRNG ON STERNAL DSG. COOL FEET WITH NOW ABSENT LEFT DP ( EASILY DOPPLERABLE PRIOR TO LAB) AND LOW CO/CI BY CCO AND SVO2 55-61. PT AWOKEN MOVED ALL EXTREM AND RESEDATED ON LOW DOSE PROP UNTIL SHEATH REMOVED. PT TO IVF AS ORDERED MD\nASSESSMENT IS AS FOLLOWS:\nNEURO: AS ABOVE. CONT ON PROP AT 20MCG OPENING EYES TO PAINFUL STIMULI. PUPILS EQUAL.\nCV: HR 60 CO 3 PER CCO WITH CI 1.8. PT TO GET 2UNIT FFP AND START LOW DOSE EPI PER DR. . BP ~120-130 ON NEO (SEE FLOWSHEET) V WIRES AT VVI 40. CT WITH CT OUTPUT OF 200 WITH 1/2 TURN. TEAM AWARE. LAST ACT 240 TO REMOVE SHEATH BY CARDS WHEN ACT<180. CONTINUE TO HAVE ABSENT LT DP EXAMINED BY DR. ALL OTHER PULSES DOPPLERABLE. PT HAS OLD ECCHYMOTIC AREA RT FEM FROM CATH ON . AREA DEMARKED AND UNCHANGED. GROIN SOFT.\nRESP: PT ON IMV 600X14 FIO2 70% WITH PO2 112 AND ACCEPTABLE VENTILATION. CONT HAVE SMALL INTERMITTENT LEAK IN CT. CXR PENDING. ? INCREASE PEEP IF CXR OKAY. LUNGS CLEAR DIMINISHED BASES LT>RT.\nGI: OGT TO LCWS LG AMT BILIOUS OUTPUT TO START CARAFATE AND PROTONIX. ABSENT BS. ABD SOFT.\nGU: CONT LG AMT HEMATURIA. UOP MARG. FOLEY TO BE IRRIGATED W/ NS 50CC/HR PER ORDER. UROLOGY TO FOLLOW. POST CATH CREAT 1.3 (PREOP 1.5) PT STARTED ON MUCOMYST AND TO IVF WITH BICARB FOR RENAL PROTECTION.\nENDO: INSULIN GTT STARTED POST CATH FOR BS >160 TITRATED PER PROTCOL SEE FLOWSHEET.\nPLAN: CONT CURRENT PLAN OF CARE, ASSESS HEMODYNAMCIS/RESP STATUS. KEEP SBP ~120 PER DR. AND CARDS. SEDATE UNTIL SHEATH DC'D, F/U CXR ? NEED PEEP . TITRATE INSULIN PER PROTOCOL. START EPI. CONT ASSESS S/S BLEEDING.\n" }, { "category": "Nursing/other", "chartdate": "2154-10-19 00:00:00.000", "description": "Report", "row_id": 1501852, "text": "RESP CARE: Pt remains intubated/on . ETT advanced 2cm to 23@ lip line MD. at present are SIMV 650/14/.50/5/5. His RSBI this am was 127!. Lungs coarse LLL, few wheezes noted bilat, Diminished RLL. Sxd small amt thick white sputum. 02 sat 97%. Plan: Slow wean to PSV.\n" }, { "category": "Nursing/other", "chartdate": "2154-10-21 00:00:00.000", "description": "Report", "row_id": 1501858, "text": "CV: SR 70's-80's with no VEA; SBP essentially 160's (goal 120's-140's) but has crept up to 170's->Lopressor dose increased and started on Lisinopril; CT and pacer wires dc'd today\n\nResp: Lungs coarse, O2 @5L per NC and sats mid 90's, pt mouth breathes and desats when sleeping->supplemental face tent @50% added at those times and sats up to high 90's; pt also desats to 80% with ambulation\n\nGI/GU: Abd soft with normoactive bowel sounds, taking po fairly well; excellent diuresis from Lasix\n\nNeuro: Intact, MAE\n\nPsych: Periods of agitation/anxiety->receiving Ativan prn\n\nEndo: BS covered by SS (see flowsheet)\n\nPlan: Cont to attempt wean of O2 and encourage use of IS; cont to monitor for ETOH withdrawal; check K+ this pm after diuresis today and repleat prn; ?transfer to 2 tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2154-10-22 00:00:00.000", "description": "Report", "row_id": 1501859, "text": "NEURO: MAE x4 to command w equal strength. A+Ox3. Conversing. Cooperative. Appear restless at HS and request sleeping med. Ativan po x1 given w effect.\n\nCV: SR 70s-80s. No vea. SBP at goal 120s-140s. Skin w/d. Peripheral pulses obtained by doppler. Afebrile.\n\nRESP: Mouth breathing w sat dropped 90s via NC when sleep. Applied oxygen cannula to mouth w sat ^97%. LS diminish in bases. RR 20s. No distress. IS use ^600ml. Effective n/p cough. CPT prn.\n\nGI: Swallow w/o difficulty. +BS/Flatus.\nENDO: BS per protocol\nGU: Foley intact draining clear urine. Huo qs w lasix\n\nWOUND: Right groin site soft and ecchymotic. Not new finding. Site marked. L buttock w duoderm intact->pain at site is relief post reposition on pillow. See flow sheet for wound care and doc.\n\nCOMFORT: No incisional pain. Support as needed.\n\nA/P: Maintain hemos. Aggressive pulm toilet. ^diet and activity. Re-assess wound care and intervention prn. ?Plan to F2 today\n" }, { "category": "Nursing/other", "chartdate": "2154-10-20 00:00:00.000", "description": "Report", "row_id": 1501856, "text": "7p-7a\nPt hemodynamics stable overnight. Pt on NO gtts. Assessed as follows:\nNEURO: Intact. No noted deficits. A/Ox3. Slightly anxious & requesting medication. Given .5mg ativan PO overnight with some effect.\n\nCARDIAC: SR without ectopy. SBP 120's-130's. Continues with SG @ 52cm. PA pressures WNL. CVPs 10-15. SVO2s >70 & CIs>2.5. S1S2 with doppler pedal pulses bilat. Feet cool/pale bilat. Continue with V-wires only which are attached to the pacer on a back-up rate of 40. CTs with minimal drainage overnight. No noted airleak/crepitus.\n\nRESP: LS clear ant & decreased post bilat R>L. O2 sats 94-98% on 50% facetent. Pt denies SOB. PaO2 on ABG this am in the 70s on 40% facetent. Nonproductive cough.\n\nGI: ABD benign. Positive BS t/o. Denies N/V. Taking po fluids without difficulty. No BM overnight.\n\nGU: F/C to gravity & patent. Urine yellow with sedament. No hematuria overnight. U/O good.\n\nSKIN: Intact. Noted lypoma on pt left gluteal with slight redness around edges, but intact. Pt states,\"I have had that for a long time\". Repositioned t/o night q3-4 hours.\n\nENDO: BS levels WNL. No coverage required overnight.\n\nPLAN: Continue to monitor VS. Ambulate pt to chair. Dicontinue SG catheter & facilitate transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2154-10-21 00:00:00.000", "description": "Report", "row_id": 1501857, "text": "7P-7A\nPt hemodynamics stable overnight. Pt assessed as follows:\nNEURO: Intact. No noted deficits. Pt a/o x3. Admits to feeling anxious. Given ativan po t/o night with good effect. Pt given percocet for pain with good effect.\n\nCARDIAC: SR 80's without ectopy. SBP 120-140s t/o night. SBP>160 @0545 this am. Given 1x dose of lopressor 5mg IV per resident with an increase made to scheduled dose to 25mg . S1S2 with weak palp pedal pulses bilat. Feet cool/pale bilat. Continue with 2V wires which are connected to the pacer back-up rate of 40. CTs to LWS with no noted airleak/crepitus. CT drainage minimal->tubes to be pulled this am.\n\nRESP: LS clear ant & decreased post bilat. O2 SATs 94-96% on 5l n/c. Pt requires face-tent at night b/c he is a mouth breather & O2 sats decrease to 90% while sleeping. Resp rate 20-24. Pt denies SOB & appears comfortable. Has productive cough ->small amount thick/yellow secretions.\n\nGI: ABD soft/distended/nontender. Has positive BS. Denies N/V. Taking PO without difficulty.\n\nGU: F/C to gravity & patent. U/O good/yellow/clear. Pt continues on scheduled dose of lasix with good response.\n\nSKIN: Intact. Continues with ?lypoma on Left gluteal. Site purple in center & red on the outside. Duoderm applied per resident. Pt reposition T/O night off of site. Pt very restless & noncompliant with staying off of site. Pt educated on importance of repositioning t/o night.\n\nENDO: Pt Requiring SS coverage. BS level currently WNL.\n\nPLAN: Continue to monitor pt hemodynamics. Facilitate CT removal & transfer to floor. Initiate discharge planning.\n" }, { "category": "Nursing/other", "chartdate": "2154-10-19 00:00:00.000", "description": "Report", "row_id": 1501853, "text": "UPDATE\nCV: EPI IV DRIP ADDED FOR LOW C.I.->NOW >2 FOR LAST 8 HRS. HR NSR MID 60'S MOST OF NOC; RARE PVC'S SEEN. MVO2 AND C.I BEST WHEN SBP CLOSE TO 140. BP/MVO2 TEND TO DROP EASILY W/ CARE/TREATMENTS. CT DRNG DIMINISHED SINCE 2U FFP TRANSFUSED. HCT DOWN TO 25 THIS A.M , LIKELY DILUTIONAL DUE TO LG FLUID INTAKE. R FEM SHEATH D/C'D LAST EVE. SITE SOFT BUT STILL ECCHYMOTIC FROM ORIGINAL CATH. FEET COOL L>R. DP/PT PULSES ALL WEAKLY DOPPLERABLE THROUGHOUT NIGHT.\n\nNEURO: ROUSES TO VOICE. INCONSISTENTLY FOLLOWS COMMANDS (MAE) AND NODS HEAD. DENIED PAIN X 1 AND NODDED YES TO PAIN X 1. PERL.\n\nRESP: LUNGS W/ SOME EXP WHEEZES THIS A.M.-ALBUTEROL MDI ORDERED. SUX/LAVAGED FOR SM AMT THICK, WHITE SECRETIONS X 1. PAO2 81% ON FIO2 .50, BICARB UP TO 25 ON D5BICARB INFUSION.\n\nG.I.: LG AMT THIN COFFEE GROUND DRNG FROM OGT, NOW LIGHTER BROWN IN APPEARANCE AND LESS.\n\nG.U.: UO BRIGHT-RED BLOODY MOST OF NIGHT. FOLEY IRRIGATED W/ 50 ML NS Q 1 HR. LOTS OF DK CLOTS OBTAINED. UO NOW LIGHT CHERRY AND MORE WATERY. CONT TO HAVE SM AMT BLOODY DRNG FROM TIP OF MEATUS.\n\nSKIN: STERNAL DSD CHANGED DUE TO SATURATION W/ BLOODY DRNG. REMAINS DRY AT PRESENT. BIL GROIN AND CT DRSGS ALSO DRY. L LEG HAS 2 STERIS @ KNEE AREA, ACE WRAP REAPPLIED. SKIN OTHERWISE INTACT.\n\nENDO: ON MOD RATE INSULIN DRIP(PER PROTOCOL) DUE TO ELEVATED GLUCOSE-LIKELY REL TO EPI DRIP.\n\nA/P: HEMODYNAMICS IMPROVED ON EPI AND W/ BP ON HIGHER SIDE(NEEDS ALSO FOR IMPROVED CEREBRAL PERFUSION). BLEEDING SLOWED AFTER FFP. OXYGENATION IMPROVING AND PT WAKING MORE NOW W/ BETTER VT'S OFF PROPOFOL. PLAN WEAN TO EXTUBATE AS TOL. CONT TO MONITOR CIRCULATION, CONT FOLEY IRRIGATION AND PAIN MED PRN.\n" }, { "category": "Nursing/other", "chartdate": "2154-10-19 00:00:00.000", "description": "Report", "row_id": 1501854, "text": "Resp. Care Note\nPt received intubated and vented on PSV 5 peep 5 and 50%. Pt with periods of RR >30, seemed mostly related to discomfort as was able to bring RR down with reassurance. Pt received lasix to aid in diuresis, was placed on SBT and after good ABG was extubated about 12:30 to 70% face tent. Strong cough effort, clearing white secretions. Albuterol MDI ordered Q6prn, received x1.\n" }, { "category": "Nursing/other", "chartdate": "2154-10-19 00:00:00.000", "description": "Report", "row_id": 1501855, "text": "EXTUBATED W/O INCIDENT TO NP'S. DOES REQUIRE ADD'L FACE MASK O2 WHILE SLEEPING TO MAINTAIN SPO2 > 92%,MOUTH BREATHER. BS COARSE W BIBASILAR CRACKLES. C & R THICK WHITE. INSTRUCTED IN TCDB'ING,INCISIONAL SPLINTING BUT REQUIRES REMINDERS.CT'S DRAINING THIN SERO SANG,NO LEAK.A & O X 3. VITS & PRN ATIVAN STARTED FOR HX ETOH USE. OCCASIONALLY DIAPHORETIC & TREMULOUS.EPI & NEO OFF W ACCEPTABLE HEMODYNAMICS & SVO2.GOAL BP ~ 120-140 MMHG.NO FURTHER EPISODES OF BRADYCARDIA SINCE LAST NOC,V WIRES SENSING APPROPRIATELY.CONTINUES ON PLAVIX & ASA POST HYBRID PROCEDURE.RECIEVED PRBC'S X 2 FOR HCT < 26% W LOW FILLING PRESSURES ,MARGINAL URINE. LASIX STARTED W ADD'L LASIX BTWN BLOOD PER DR. . DIURESED WELL,URINE PRESENTLY CLEAR PINK TINGED-YELLOW.HAD REQUIRED HAND IRRIGATION FOR RED URINE W CLOTS PREVIOUSLY.OOB->CHAIR W 2 ASSISTS,TOL. WELL.ADVANCED TO CLEAR LIQS.GLUCOSES < 50 DESPITE REMOVAL OF INSULIN GTT,D50 GIVEN W IMPROVEMENT. ADVANCED TO Q 6 HR GLUCOSES W SSRI AS DIET HAS ADVANCED.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2185-08-02 00:00:00.000", "description": "Report", "row_id": 1794486, "text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 13.\nWt: 2480 g (+40)(~25th to 50th %Ile); birth wt: 2315 g. Average wt gain over past wk ~17 g/kg/day.\nHC: 28.5 cm (<10th %Ile); last: 28 cm\nLN: 46.5 cm (~25th to 50th %Ile); last: 46.5 cm\n not needed\nNutrition: 150 cc/kg/day SSC 24, alt po/pg over 90 feeds due to hx of spits. Average of past 3 day intake ~150 cc/kg/day, providing ~120 kcal/kg/day and ~3.3 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. not needed. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN shows no change over past wk; suspect measurement was not taken. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-02 00:00:00.000", "description": "Report", "row_id": 1794487, "text": "0700-1900 NPN\n\n\n: in to visit this afternoon. Involved and\n. Updated on infant's current status/plan of care by\nthis RN. Continue to support family.\n\nFEN: TF=150cc/kg/d of SSC24 alt PO/PG q4hr. Infant bottled\n65cc with good coordination at 1330. Gavage feedings given\nvia NGT over 90 . Abdomen pink, soft, round, +BS, no\nloops. No spits, no aspirates. Voiding and stooling (guiac\nnegative). Continue to monitor FEN status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Brings hands to face, likes\npacifier. MAE. Continue to support G+D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-02 00:00:00.000", "description": "Report", "row_id": 1794488, "text": "Neonatology-NNP Progress Note\nPE: remains in her crob, in room air, bbs cl=, rrr s1s 2no murmur,abd soft, nontender, V&S, afso, active with care\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794422, "text": "Resp care\nPt remains supported on 6cm/h2o of NCPAP, 21-30% mostly\nRR- 40-80's w/ mild/moderate retractions\nB/S clear, sx small amount of cloudy secretions\nBaby has been labile w/ O2 sats, requiring increases of Fio2\nPlan: Continue support\n" }, { "category": "Nursing/other", "chartdate": "2185-07-31 00:00:00.000", "description": "Report", "row_id": 1794478, "text": "NICU NURSING PROGRESS NOTE:\nRESP.O: Infant remains in RA. RR: 40-60, sating 96-100%.\nLungs clear and equal. Mild subcostal retractions. No spells\nor desats. Continue to monitor.\n\nParenting: Mom called this morning to update. Both \nin for the 13:00 care. Updated at the bedside regarding\ninfant's plan of care by RN . Mom did the care and\nbottled the baby. got to held the baby. \nhandle the care. and caring . Continue to\nsupport and educate.\n\nFEN.O: Infant remains on 150cc/k/d of SC24, 60cc Q4 hrs.\nOffered bottle, took 15cc. Remainder suplemented by gavage.\nAbdomen exam is soft, round, no loops. BS active. Voiding,\nno stools. aspirates. No spits. Tolerating feeds.\nContinue to encourage PO feedings.\n\nG/D.O: Infant in open crib. Temps are stable. Active and\nalert with cares. Wakes for feeds. Sleeps well in between\ncares. Got her immunization, hepB this morning. A: AGA.\nP: Continue to support developmentally needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-31 00:00:00.000", "description": "Report", "row_id": 1794479, "text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; PCA. Hep B vaccine given by this RN.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-01 00:00:00.000", "description": "Report", "row_id": 1794480, "text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in RA with RR 50-60s. Sats >96%.\nMild IC/SC retractions. Lung sounds are clear. No spells\nnoted so far this shift.\n\n2. PAR: in to do cares this evening.\n\n3. F&N: TF remain at 150cc/k/d of Special Care Similac 24\ncal. She bottled 17cc with Mom at 2100. Abd benign. BS+.\nNo spits and minimal apsirates noted. Voiding well. No\nstool noted so far this shift. Weight gain 30 grams.\n\n4. DEV: is active and alert duirng her cares. Temp\nstable swaddled in open crib. She sucks on her pacifier and\nputs her hands to her face.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-01 00:00:00.000", "description": "Report", "row_id": 1794481, "text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing.\n\nWt 2440 up 30. Tolerating feeds at 150 cc/k/d of 24 cal. Abdomen benign. STill requiring gavage. PO improving.\n\nTemp stable in open crib.\n\nAwaiting maturation of resp control and feeds.\n\nState lab to be checked ensure receipt.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-01 00:00:00.000", "description": "Report", "row_id": 1794482, "text": "NPN 0700-1900\n\n1 Alt in Resp. r/t prematurity\n\nRESP: Remains in RA, LS C/=, mild SCR. No spells in >24'.\nProblem resolved.\n\n: Mom readmitted to L&D for bleeding. Both in\nto visit in between cares this afternoon. Updated by\nthis RN, asking lots of appropriate questions. Mom was to be\ndischarged home this afternoon - Dad plans to visit again\nthis evening.\n\nFEN: Alternating PO/PG feedings, poor bottle feeder - needs\nlots of encouragement. No spits, minimal aspirates. Abdomen\nsoft/round, good bs, V&S (heme negative).\n\nG/D: Temp stable swaddled in OAC. A&A w/cares, sleeps well\nin between. Starting to wake for feedings. Repeated hearing\nscreen for right ear only - passed. Sucks on pacifier for\ncomfort.\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in Resp. r/t prematurity; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-01 00:00:00.000", "description": "Report", "row_id": 1794483, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\nmild subcostal retractions in room air,lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n\nupdated mother by phone today.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794423, "text": "Neonatology NP Note\nPE\nnested on radiant warmer\nAFOF\nmild subcostal retractions, tacypneac, lungs with scattered crackles, good air entry\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended\nactive with appropriate tone\n\nMet with mother at bedside, updated on progress and possible need for intubation for surfactant later today.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794424, "text": "NPN 0700-1900\n\n\n#1: O: Infant remains on CPAP of 6 in room air to 40% O2,\nmaintaining sats greater than 92%. RR 40's-80's with\nsubcostal retractions. Chest x-ray done due to increased O2\nrequirement and tachypnea. Results pending. CBG done, see\nlab results. P: Continue to monitor infant and intervene as\nnecessary.\n\n#2: O: Mom has called and visited off and on this shift. NNP\nupdated mom at bedside. A: Loving and concerned parent. P:\nContinue to support parents in the care of their infant.\n\n#3: O: Infant is NPO and continues on 80cc/kg of D10 through\nperipheral IV. Lytes: 139/3.9/105/23. Bili 5.3/0.3. NNP\nnotified of results. Electrolytes will be added to IV fluid\nthis evening. TF will be increased to 100cc/kg. Dsticks this\nshift were 86 and 77.\n\n#4: O: Temp stable on warmer. Infant is alert and active.\nBrings hands to face for comfort and sucks pacifier when\noffered. Remains nested on warmer. A: AGA. P: Continue to\nsupport growth and development.\n\n#5: O: Infant started on amp and gent related to need for\nrespiratory support. P: Continue with antibiotics as\nordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794425, "text": "Procedure Note\n\nBaby intubated orally with a 3.0 endotracheal tube after medication with fentanyl.\nBaby tolerated procedure well.\nTube noted to be slightly high on CXR and adjusted by pushing it in 1cm.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794426, "text": "Procedure Note\n\nCorrection - tube was low - pulled back 1cm.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794427, "text": "Procedure Note\n\nCorrection - tube was low - pulled back 1cm.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794428, "text": "Procedure Note\n\nCorrection - tube was low - pulled back 1cm.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794429, "text": "Respriatory Care\nBaby received on imv 30 26/6,fio2 40%.Received 2nd dose of 9.5 cc 7.33/43 weaned r->25.Baby still fio2~ 40%,cxr taken,? of pneumo,rpt'd cxr with lateral,pneumo ruled out.cbg @ 0500 7.40/42 weaned pip 22/6 R weaned to 20,fio2 36% at this time.received fent x 1 for sedation.BS,lg air leak.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-07 00:00:00.000", "description": "Report", "row_id": 1794512, "text": "NPN\n\n\n#2Parenting:\nO: Mom called and given update. Plan to visit this evening\nand complete discharge teaching. Mom offered , Mom plans\nto arrange Pedi visit.\nA: Involved family\nP: Cont to support and inform\n\n#3FEN:\no: Changed formula to 20. Abd. soft, active BS, no\nloops. Bottling all feeds well.\nA/P: Cont to feed adlib.\n\n#4G@D:\nO: Alert and active with cares. MAE. Ant font soft and flat.\nTemps stable in open crib.Pssed car seat test.\nA/P: Cont to support G@D\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-08 00:00:00.000", "description": "Report", "row_id": 1794513, "text": "#2 MOM AND DAD IN FOR EVENING CARES. INDEPENDANT\nWITH CARES. TOOK CPR CLASS. PLANNING FOR A.M. D/C.\n#3 WAKING TO FEED Q3-4HR, PO FEEDING WELL. WEIGHT INCREASE\n10GM. NO STOOL AT THIS TIME IN SHIFT.\n#4 STABLE IN OPEN CRIB. ALERT AND ACTIVE. PO FEEDING WELL.\nD/C IN A.M.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-30 00:00:00.000", "description": "Report", "row_id": 1794474, "text": "NICU NURSING PROGRESS NOTE:\nRESP.O: Infant remains in RA. RR: 40-60. Sating 96-98%.\nLungs sound clear and equal. Mild subcostal retractions. No\nspells or spont. desats. Continue to monitor and assess.\n\nParenting: Both and grandmom in for cares. Updated\nregarding infant's status and plan of care by RN .\n did the care and bottled her. handle the\ncare and the baby well. and involving family.\nContinue to support and keep informed.\n\nFEN.O: TF=150cc/k/d of Similac 24cal, 59cc Q4 hrs. Offered\nbottle 2x. taking between 10-20cc. Abdomen exam is soft,\nround, no loops. BS active. Girth stable at 25cm. Voiding,\nno stools. Max aspirates 1cc. Small to large spits. Continue\nto encourage PO feeding and monitor spits.\n\nG/D.O: Infant is in open crib. Maintaining temps. Active and\nalert with cares. Wakes for feeds every 4 hrs. Sleeps well\nin between cares. given a bath and it was\ndemonstrated by RN . A: Appropriate behavior.\nP: Continue to support developmentally needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-08 00:00:00.000", "description": "Report", "row_id": 1794514, "text": "Neonatology NP Note\nDischarge PE\nvigorous, nondysmorphic preterm infant\nAFOF, sutures approximated\n+ bilateral red reflex, conjuntiva clear\npalate intact, oral mucosa clear\nneck supple and without masses\nclavicles intact\nrespirations comfortable, lungs clear/=\nRRR, no murmur,pink and well perfused\nliver edge at RCM, abdomen soft, nontender and nondistended, active bowel sounds, cord healed\nnormal female genitalia\nstable hip exam\nno sacral anomalies\nnormal digits and creases\nsymmetric tone and reflexes.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-08 00:00:00.000", "description": "Report", "row_id": 1794515, "text": "NSG discharge note\n\nInfant discharged to home today with .Infant alert. pink active. Lungs cl=. No murmur. Abd. exam benign. Bottled well. stooled lg amt. given final discharge instructions. Mom declined appt. Mom plans to arrange pedi appt on with Dr. . Car seat instruction reviewed. Mom given to Sleep pamphlet and reviewed infant positioning and SIDS prevention, Infection prevention and signs of sick infant.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-08 00:00:00.000", "description": "Report", "row_id": 1794516, "text": "NeonatologyDoing well. RA. NO spells.\n@WT 2695 up 10. Toleratign feeds. Good intake. Abdomen ebnign\n\nReday fort dc.\n\nPMD appointment made.\n arranged.\nDC summary dictated.\n\nPMD contact.\n\nPassed hearing.\n\nDC prep time 35 minutes.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-25 00:00:00.000", "description": "Report", "row_id": 1794449, "text": "Neonatology\nIn low flow NCO2. Comfortable appearing. Last CXR on Sat shows resolution of air leak. Will wean from O2 as tolerated.\n\nWt 2220 down 20. Tolerating feeds at 80 cc/k/d out of TF of 140 cc/k/d. ABdomen benign. Will increase rate of feeding advancementa s IV access out.\n\nUnder photorx for bili in 12 range. Will recheck in am.\n\nCOntinue as at present. Monitor feed advancement.\n\nFamily meeting held over weekend.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-25 00:00:00.000", "description": "Report", "row_id": 1794450, "text": "Neonatology NP Note\nPE\nnested in isolette under phototherapy\nAFOF, sutures opposed\nmild subcostal retractions, + pectus in NCO2, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\nface and trunk jaundice\n\nUpdated parents at bedside, they are pleased with her progress.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-29 00:00:00.000", "description": "Report", "row_id": 1794468, "text": "NPN 7:00-19:00\n\n\nRESP - Infant remains in RA. RR 40-60 and O2 saturation\n97-100%. No desats thus far this shift. LS cl/= bilaterally.\nBreathing comfortably. Continue to monitor resp. status\n\n - Mom called this morning. Updated up R.N. Mom was\nplanning on visiting at 13:00, but called to say she wasn't\nfeeling well and would try to come in later. Continue to\neducate, support and update .\n\nFEN - TF 150cc/k/d of SC24 = 58cc q4. PO/PG. Bottled x1 this\nshift. Infant was not interested in bottling and POed 6cc.\nRemainder of feed gavaged. Infant had one lg spit thus far\nthis shift and asp. Abd is soft, +bs, no loops. Voiding\nand stooling, heme-. Continue to monitor tolerance to feeds\nand encourage PO feeding.\n\nG&D - Maintaining temps while swaddled in OAC. Sucks on\npacifier and brings hands to face. Waking on own for some\ncares. Alert and active during cares. FS&F. MAEs. Continue\nto support G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-29 00:00:00.000", "description": "Report", "row_id": 1794469, "text": "NPN DAYS\nI have examined and agree with above note by PCA.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-29 00:00:00.000", "description": "Report", "row_id": 1794470, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\nmild subcostal retractions in room air,lungs clear/=\nRRr, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone.\n\nTalked with mother on phone updated on progress and plan.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-30 00:00:00.000", "description": "Report", "row_id": 1794475, "text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; PCA. able to give bath today with some assistance. D/C teaching initiated; see NICU D/C instruction form. aware that the unit offers CPR for and they plan to sign up for a class. Cont to educate .\n" }, { "category": "Nursing/other", "chartdate": "2185-07-31 00:00:00.000", "description": "Report", "row_id": 1794476, "text": "NPN\n\n\n#1Resp:\nO: remains in RA. RR 50's. Lungs cl=, no spells. color pink\nwell perfused\nA/p: Cont to monitor\n\n#2Parents:\nO: in to visit and handling infant well. Plan to\nvisit X2/ day . Dissapointed with feeding effort\nA/P; Cont to support and inform.\n\n#3FEN:\no: wt 2.410(+70 gms) On 150cc/k/d SSC24 Bottled 15cc. Tol\ngavges well. No spits. voiding qs, no stool. HOB elevated.\nAbd exam soft, active BS, No asp.\nA: Pot for spitting\nP: Cont to monitor\n\n#4G@D:\no: temps stable in open crib. ant font soft and flat. MAE.\nWaking for feeds on own. sucking on pacifier.\nA/P: Cont to ssupport G@D\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-31 00:00:00.000", "description": "Report", "row_id": 1794477, "text": "Neonatology\nDoing well. Remains in RA. Comfortable apeparing.\n\nWt up 70 Tolerating feeds at 150 cc/k/d of 24 cal. STill requiring gavage. Abdomen benign.\n\nCOntinue as at present. Awaiting maturation of resp contorl and feeds.\n\nRight ear referred on testing yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-20 00:00:00.000", "description": "Report", "row_id": 1794415, "text": "Resp care\nPt transported to NICU & placed on 6cm/h2o of NCPAP, 21-23%\nfor increased WOB. CXR reflects mild RDS.\nCPAP increased to 7cm/h2o\nPt tolerating well, RR- 30-60's w/ mild/moderate retractions\nCPAP just weaned back to 6cm/h2o\nPlan: Continue support, monitor WOB\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-20 00:00:00.000", "description": "Report", "row_id": 1794416, "text": "1 Alt in Resp. r/t prematurity\n2 Alt. in parent r/t separation\n3 Alt. in FEN\n4 Growth and Development\n5 Pot. for infection\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in Resp. r/t prematurity; added\n Start date: \n 2 Alt. in parent r/t separation; added\n Start date: \n 3 Alt. in FEN; added\n Start date: \n 4 Growth and Development; added\n Start date: \n 5 Pot. for infection; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-20 00:00:00.000", "description": "Report", "row_id": 1794417, "text": "Admission Note\n\n\nInfant admitted to NICU for prematurity (34 5/7weeks). \nabove MD note for maternal history and delivery events.\n\n1. Infant arrived to NICU in RA and started to grunt and\nhad 3 desats to 78% requiring BBO2. Lungs initially\ndiminished. PLaced on prong cpap 6, FiO2 21-25%. CXR\nobtained. Occassional desats to mid 80's. Lungs more\nclear. RR 50-80's with mild SC retractions. No A&B's thus\nfar. Cont to monitor resp. status and support as needed.\n\n2. Father in to visit and updated on plan of care. Father\nin to visit with other family memebers as well. Cont to\nsupport and update parents.\n\n3. BW= 2315gm. TF at 80cc/k/d of D10W. Initial dstick\ndropped from 55 to 46 and a D10W bolus given and IVF\nstarted. Dsticks now stable 89 and 111. Abd soft, pink, no\nloops, +BS. No void or meconium thus far. Plan to obtain\n24hr lytes and bili as per team. Cont to monitor dsticks\nclosely and support as needed.\n\n4. Infant placed under warmer and able to wean; see\nflowsheet for details. Alert and fiesty at times. MAE.\nBaby meds given. Cont to promote G&D.\n\n5. CBC and diff obtained and benign. Blood cultures sent.\nNo antibiotics started at this time. Cont to monitor for\ns/sx of infection.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794418, "text": "Respiratory Care Note\nPt. continues on 6cmH2O of nassal prong CPAP and 21%. BS are clear. Pt.'s cap gas overnight was 7.28/51/37/25/-3. Pt. appears comfortable. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794419, "text": "NPN\n\n\n#1 resp-Remains on Prong CPAP of 6cms in 21%.BS clear. Sxn\nx1 for sm amts.RR= 50-80's.Mild\nretractions.CBG=7.28/51/37/25/-3.\n#2 Mom here to visit x2+ called x1. Updated on pt\ncondition.Will be back to visit in AM.\n#3 F/N- Abd soft,+bs, no loops.Remains NPO.PIV patent\ninfusing at 80cc/kg/day of D10w.D/S=138.Voiding in adeq\namts. no stool yet.\n#4 Dev-Nested in sheepskin on open servo warmer.Alert+\nactive w/cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794420, "text": "Case Management Note\nHave reviewed chart & placed lists of Early Intervention Programs & VNA's in chart. I will cont to follow & assist w/any d'c plans w/team & family inputs.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-21 00:00:00.000", "description": "Report", "row_id": 1794421, "text": "Neonatology\nOn CPAP. Comfortable apeparing. Fio2 approx RA at most times.\nNo evidence of PDA on exam. CV stable.\n\nWT 2315. NPO at present. TF at 80 cc/k/d. Abdomen benign. Will begin feeds this afetrnoon\n\nAmp/Gent to be started.\n\nBili to be checked with lytes this afternoon.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-30 00:00:00.000", "description": "Report", "row_id": 1794471, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 95-100%.RR 40-60's with\nmild retractions.LS clear and equal b/l.No A's,B's or desats\nnoted.A:Stable P:Cont. to assess resp. status.\n\nParenting: in tonight very loving and\ninvested.Needing some assisstance with cares.Asking\nappropriate questions.A/P:Cont. to update,support,and\neducate.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day,rec.Similac SC 24\n59cc's q 4 hrs.Gavaged over 90 . d/t spits.Attempted to\nbottle with mom however no interest.Weight=2.340 kg up 20\ngrams.Abd. soft with pos bs,no loops or spits,minimal\naspirates.Girth 27-25.5.Infant voidinng no stool thus\nfar.HOB remains elevated.A:Stable P:Cont.to assess tolerance\nof feeds and monitor weight gain.\n\nG/D:AFSF.Infant appears alert and active with care.Sleeps\nwell b/t.Presently swaddled with nested boundaries.Temp.\nmaintained in open crib.MAE.Sucking intermitently on\npacifier.A:AGA P:Cont. to support growth and dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-30 00:00:00.000", "description": "Report", "row_id": 1794472, "text": "Neonatology Attending\n\nDOL 10 CGA 36 week\n\nStable in RA. No A/B.\n\nNo murmur. BP 67/31 mean 45.\n\nOn 150 ml/kg/d SC 24 pg with feeds over 1.5 hrs secondary to spits. Minimal po with bottle. Voiding. Stooling. Wt 2340 grams (up 20).\n\n in and up to date. Mother with infected incision.\n\nA: Stable. No spells. Needs to learn to feed.\n\nP: Monitor\n pos as tolerated\n Hep B vaccine\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-30 00:00:00.000", "description": "Report", "row_id": 1794473, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal. NL S1S2, no audibl emurmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-06 00:00:00.000", "description": "Report", "row_id": 1794504, "text": "#2Parent\nmom called and informed baby could go home if she cont to\nbottle well.\n#3FEN\nWt 2.655 up 50. awake and eager for feeds. She took\n65/50/65 SC24. Abd soft, active bowel sounds. Void but no\nstool. asp. No spits.\nA. Bottled well this shift\nP. Cont to monitor po feed ability as well as weight gain\n#4Dev\nTemp stable in an open crib. Bottling well, Slept well\nbetween cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-06 00:00:00.000", "description": "Report", "row_id": 1794505, "text": "NICU Attending Note\nDOL # 17 = 37 week CGA learning to PO feed.\n\nPlease see full \n\nCVR/RESP: RRR with no murmur, BS clear/=, RA, No A/B. Will continue to monitor.\n\nFEN: Abd benign, weight today 2655 gm, up 50 gm, on ad lib PO feeds, 130 cc/kg/d minimum, SC 24, taking all bottles x 12 hours. Will continue current diet, continue to encourage PO intake. If continues to fully PO feed, will be ready for d/c to home in next few days.\n\nDISPO: Discharge teaching/testing ongoing. Still needs car seat test. need to take CPR.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-06 00:00:00.000", "description": "Report", "row_id": 1794506, "text": "PCA Note 7a-3p\n\n\nPARENT: Parent called x1. Updated over the phone by RN\n. Plan to come in @ 1700. Continue to update and\nsupport as needed.\n\nFEN: TF 130cc/k/d of SC24 = 58cc Q4. Infant bottled\n55-60cc Q4. Tolerating feeds well; no spits. Abd. soft,\nround, good BS, no loops noted. Voiding with trace to small\nstool this shift. Minimal aspirates. Continue to encourage\nPO's.\n\nDEV: Infant swaddled in OAC. Temps remain stable. MAE.\nSucks on pacifier to calm oneself. Continue to support\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-06 00:00:00.000", "description": "Report", "row_id": 1794507, "text": "NPN0700-\nI have examined the infant and agree with the above written by Q. Tran, PCA.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-06 00:00:00.000", "description": "Report", "row_id": 1794508, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\ncomfortable respirations in room air,lungs clear/=\nRRR, no murmur, pink and wellperfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n\nupdated mother at bedside, anticipating discharge soon.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-07 00:00:00.000", "description": "Report", "row_id": 1794509, "text": "NICU NPN 1900-0700\n\n\nPARENTING O: Mom and dad in for a visit during the evening,\n toward baby ,and asking questiones re d/c.\n\nFEN O: Tf remain at 130cc/k/d. She is po feeding well,\nwaking every 3-4 hrs, and tolerating well. Abdominal exam\nbenign, no spits, voiding and stooling. She is gaining\nweight, up 30g tonight.\n\nDEV O: Temps are stable, swaddled in crib. She is alert and\nactive with cares, Sleeps well in between cares. Fontanells\nare soft and flat. Takes pacifier for comfort.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-07 00:00:00.000", "description": "Report", "row_id": 1794510, "text": "Neonatology Attending Note\nDay 18\nCGA 37 2\n\nRA. RR40-50s. Cl and =. No A&Bs. HR 130-150s. No murmur. Pink, well perfused.\n\nWt 2685, up 30 gms. 130 SC24. TFI: 155. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant progressing well. Will decrease cals to 20 and change to standard Similac with anticipated plans for discharge in am if does well.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-07 00:00:00.000", "description": "Report", "row_id": 1794511, "text": "Neonatology Attending Note\nExam:\nResting comfortably in open crib. AFSF. Lungs CTA, =. CV RRR, no murmur, 2+FP, pink. Abd soft, +BS. Ext pink, well perfused, full ROM.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-28 00:00:00.000", "description": "Report", "row_id": 1794464, "text": "Clinical Nutrition:\nO:\n~36 week CGA BG on DOL 8.\nWT: 2255g(+45)(25-50 %ile); birth WT: 2315g. WT is down ~3% from birth wt.\nHC: 28cm(<10 %ile); HC @ birth: 31.5cm\nLN: 46.5cm(~50 %ile: LN @ birth: 46.5cm\nLabs noted.\nNutrition: 150cc/kg/day as SSC 24; po/pg. Projected intake for next 24hrs ~150cc/kg/day, providing ~120kcal/kg/day & ~3.3g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; /pg, takes volumes po. Labs noted & within acceptable ranges. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is not yet meeting recs of ~15g/kg/day for WT gain, ~0.5-1.0cm/wk for HC gain & of ~1.0cm/wk for LN gain; feeds adv yesterday. Will monitor trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-28 00:00:00.000", "description": "Report", "row_id": 1794465, "text": "Nursing NICU Note.\n\n\n1. Resp. O/Pt remains in RA. No tachypnia noted by this\nnurse this shift thus far. No desaturations or A/B noted\nthis shift thus far. A/REsp status appears stable in RA at\nthis time. P/Cont. to monitor for s/s of resp. distress.\n\n2. Parents. O/Mother in this afternoon for cares. Mother\nupdated on pt's status and plan of care. Mother attempted to\nbottle feed pt. Mother demonstrated good bottle feeding\ntechnique, however pt was not interested in bottle feeding\nat that time. A/Mother is actively involved in pt's care.\nP/Cont. to support and educate. Cont. discharge preparation.\n\n3. F/N. O/TF remain at 150cc/k/d of SC 24 po/pngt.\nPlease refer to flowsheet for examinations of pt from this\nshift. Pt not interested in bottle feeding this afternoon.\nVoiding. Passing stool. A/Appears to be tolerating present\nfeeding regime. P/Cont. to monitor for s/s of feeding\nintolerance.\n\n4. G/D. O/Temp remains stable swaddled in an open air crib\nat this time. Awake and alert at care times and sleeping\nwell in between. Held by mother. Rooting and sucking on\npacifier. A/Alt. in G/D. P/Cont. to support pt's growth and\ndev. needs.\n\n6. bili. O/Skin pale-pink. Remains off phototherapy at this\ntime. A/Resolving hyperbili issue. P/Cont. to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-29 00:00:00.000", "description": "Report", "row_id": 1794466, "text": "NPN 7p-7a\n\n6 Bili\n\nRESP: remains in RA, RR 40-60, sats >95%. Mild\nretractions. Cont to follow exam.\nParents: Parents in to visit tonight. Updated on current\nplan of care.\nFEN: TF @150cc/kg/day of SC24 cals = 58cc Q4 hours, over 1\nhour. spits x2 tonight. girth 24.5cm, Po fed x1 15cc\nfairly. Wt up 65 grams to 2320. stooled x3 tonight. cont\nto follow and encourage PO's.\nG and D: Temp stable on open crib. active and alert with\ncares.\n\n\nREVISIONS TO PATHWAY:\n\n 6 Bili; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-29 00:00:00.000", "description": "Report", "row_id": 1794467, "text": "Neonatology\nRA. Comfortable. Spells not problem.\n\nWt 2320 up 25. Tolerating feeds with some spits. Abdomen benign.\n\nTemp stable\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-20 00:00:00.000", "description": "Report", "row_id": 1794414, "text": "Admission Note\nOb-\nPedi- \n\nBaby girl is the 2315 gram product of a 34 week gestation EDC born to a 34 you G4 P2 mom with PNS A+ antibody negative Hep B negative, RPR NR, Rubella Immune, and GBS unknown.\n\nPregnancy complicated by a partial previa with bleeding episodically during the pregnancy. She was born by C-section because of the previa.\nHer Apgar score were 8 (1 min) 9 (5 min).\n\nThere was no fever, ROM at the delivery.\n\nShe was taken to the NICU for further evaluation.\n\nExam: gen infant with obvious grunting and intercostal retractions\nweight 2315 grams (50%) length 46.5 cm (50%) HC 31.5 cm (50%)\ntemp 97.6 HR 153 RR 32 BP 63/30 mean 43 sat 96% in room air d-stick 55\nHEENT-normocephalic atruamatic ant font open flat palate intact\nneck supple\nchest intercostal retractions intermittent grunting and occassional nasal flaring\nCV regular rate and rhythm no murmur femoral pulses 2+ bilaterally\nAbd soft with active bowel sounds no masses or distention\nExt cap refill brisk warm well perfused\nHips stable\nClavicles intact\nGU normal premature female\nAnus patent\nSpine midline no sacral dimple\n\nImp-infant with respiratory distress likely due to unlabored C-section\nwill begin CPAP and monitor respiratory status will consider intubation\nWill begin IVF at 80 cc/kg/day\nWill check a CBC and blood culture\nWill begin antibiotics if CBC is abnormal\n" }, { "category": "Nursing/other", "chartdate": "2185-08-04 00:00:00.000", "description": "Report", "row_id": 1794496, "text": "NPN 7:00-19:00\n\n\nFEN - TF 150cc/k/d of SC24 PO/PG = 63cc q4. Bottling 45-65cc\nwith each feed. Remainder of feed gavaged. Good coordination\nwith bottling. One sm. spit and no asp. Abd is soft, +bs, no\nloops. Voiding. No stool thus far this shift. Continue to\nencourage PO feeding.\n\nG&D - Stable temps while swaddled in OAC. Infant waking on\nown for cares. Alert and active. Infant is showing more\ninterest in bottling. FS&F. MAEs. Continue to support\ndevelopmentally.\n\n - and older brothers visited this afternoon.\n independent with cares. Ask appr. questions.\nContinue to educate and support .\n\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-04 00:00:00.000", "description": "Report", "row_id": 1794497, "text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; PCA. Mother updated on infant plan of care by this RN.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-05 00:00:00.000", "description": "Report", "row_id": 1794498, "text": "#2Parents\n here at 2100. Mom bottled baby. called for an\nupdate at 0700\n#3FEN\nWt 2.605 up 70. Baby cont to receive 24. Baby bottled\n50/63/60. Abd soft, active bowel sounds. Void, no stool. no\nspits. asp.\nA. Tol feeds. Improving with bottling\nP. Cont to monitor\n#4Dev\nTemp stable in an open crib. Awakening for feeds. Bottling\nimproved.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-05 00:00:00.000", "description": "Report", "row_id": 1794499, "text": "Neonatology\nDoing well. Remains in RA. Comfortable appearing. No spells.\n\nWt 2605 up 70. Tolerating feeds at 150 cc/k/d of 24 cal. Moving toward full feeds. Still requiring some gavage. ABdomen benign. Will decrease TF to 130 cc/k/d and monitor intake/growth.\n\nTemp stable. Active and alert\n\nCOntinue as at present.\n\nAwaiting maturation of resp control and feeds.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-23 00:00:00.000", "description": "Report", "row_id": 1794440, "text": "Nursing PRogress note\n\n5 Pot. for infection\n\n1. Resp O/A Rec'd inf intubated. Infant is currently in\nNC 200cc 100%. IC/SCR noted. No incr WOB noted. No spells\nthus far. P cont to assess resp needs.\n2. Parents O/A Mom and DAd in for visit and cares.\nUpdates given. FAmily meeting with today. P cont\n to support, educate.\n3. FEN O/A TF incr today to 120cc/kg/day. IVF currently\nat 90cc/kg/day of PND10 running at 8.1cc/hr Lipids running\nat 0.5cc/hr via PIV. Ent feeds started at 30cc/kg/day of\nSC20. Tol well, no spits thus far. No asp thus far. Belly\nsoft, no loops. Inf voiding, no stool thus far. P Incr ENt\nfeeds by 15cc/kg/day due at 0100 and 1300.\n4. DEV O/A is swaddled on an off warmer. Likes\nbinkie. P will place infant in OAC if stable temp at next\ncares.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 5 Pot. for infection; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-23 00:00:00.000", "description": "Report", "row_id": 1794441, "text": "Neonatology-NNP Progress NOte\n\nMet with parents to review clinical issues and criteria for discharge\n\nWill continue to keep informed\n" }, { "category": "Nursing/other", "chartdate": "2185-07-24 00:00:00.000", "description": "Report", "row_id": 1794442, "text": "NPN\n\n\n#1 RESP-Remains in NC 200cc 100% o2. BS clear. Mild\nretractions.RR- 40-70.No A's or B's or increased WOB.\n#2 Mom+ Dad here x2 to visit and called x2.\nUpdated.Held baby x20mins.\n#3 F/N- Abd soft,+ bs, no loops. Tolerating ng feeds of SC20\ncals at 45cc/kg/day w/o spits. Feeds advancing by\n15cc/kg/day as tolerated. voiding+ stooling in adeq amts.Wt\ndown 15gms.Tf= 120cc/kg/day. PIV patent and infusing D10\nTPN+ IL.Lytes+ bili drawn+ PND.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-24 00:00:00.000", "description": "Report", "row_id": 1794443, "text": "Attending Note\nDay of life 4 CGA 35 \novernight nasal cannula 200 cc of FiO2 100% currently in 75 cc of nasal cannula\nno spells\nno murmur HR 130-150 BP 63/41 mean 56\nbili 14.1/0.4 up from 8 before now on single photo\nweight 2340 down 15 grams on 140 cc/kg/day IVF at 95 cc/kg/day PN/IL\nenteral feeds 45 cc/kg/day of SSC 20 cal/oz all pg advance enteral 15 cc/kg/day \nUO 3.3 cc/kg/day passed mec\nDstick 66 Na 138 K 6 Cl 108 CO2 21\nin low air isolette\n\nImp-stable currently\nwill continue to advance enteral feeds\nwill recheck lytes and bili in the am\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-24 00:00:00.000", "description": "Report", "row_id": 1794444, "text": "Attending Note\nPhysical Exam\ngen wide awake very active and alert\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds\nExt warm well perfused briks cap refill\nSkin jaundiced on the face and upper torso\n" }, { "category": "Nursing/other", "chartdate": "2185-07-24 00:00:00.000", "description": "Report", "row_id": 1794445, "text": "Attending Note\nPhysical Exam\ngen wide awake very active and alert\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds\nExt warm well perfused briks cap refill\nSkin jaundiced on the face and upper torso\n" }, { "category": "Nursing/other", "chartdate": "2185-07-24 00:00:00.000", "description": "Report", "row_id": 1794446, "text": "Attending Note\nPhysical Exam\ngen wide awake very active and alert\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds\nExt warm well perfused briks cap refill\nSkin jaundiced on the face and upper torso\n" }, { "category": "Nursing/other", "chartdate": "2185-07-27 00:00:00.000", "description": "Report", "row_id": 1794457, "text": "NPN\n\n\n#1resp:\nO: Infant weaned to RA with sats maintained in mid 90's. RR\n40-60, mild IC/sc retractions. sx'ed nares small thick plug.\nA/P: Cont to monitor sats and WOB\n\n#2Social:\nO: Parents in to visit. handling infant with assistance.\nConcerned about O2 requirement. Mom called and given update\nA/P: Cont to support and inform\n\n#3FEN:\nO: wt 2.210 (+20) On 150cc/k/d SSC20. abd. soft, active BS,\nno loops. Mod spit X1 Voiding qs, passed small mec\nA/P: Cont to monitor wts.\n\n#4G@D:\nO: Temps stable in heated isolette with infant under bili\nlight, Alert and active with cares, MAE. Ant font soft and\nflat.\nA/P: Cont to support G@D\n\n#6 BILI:\nO: Under single phototx. with eye patches in place. A\nA/p: Check bili in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-27 00:00:00.000", "description": "Report", "row_id": 1794458, "text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing.\n\nWt 2210 up 20. Tolerating feeds at 150 cc/k/d. 20 cal Abdomen benign. Will increase cals to 24 to as tolerated. Taking 15-30 cc po rest via agavge.\n\nUnder photorx . Bili 5 range this am. Will dc photorx and recheck in am.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-27 00:00:00.000", "description": "Report", "row_id": 1794459, "text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF\nmild subcostal retractions in NCO2, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-27 00:00:00.000", "description": "Report", "row_id": 1794460, "text": "1. remains in RA, RR50-60, BBs clear, equal, mild sc\nretractions, brief sat drift to 88 P: continue to monitor\nand assess.\n2. Parents here for 1300 cares, Mom held baby for 20 .\ncontinue to provide updates, educate and offer support.\n3. TF 150cc/k/d SC 24 58cc q4, took 30cc po then tired, abd\nstable, voiding and passing stool.\n4. temp warm x1 swaddled in heated isolette, temp weaned,\nactive and very alert with cares, sucking well on pacifier\nP; continue to support growth and development.\n6. phototherapy dc'd ~10 for am bili of 5.5/0.3 P; check\nrebound bili in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-28 00:00:00.000", "description": "Report", "row_id": 1794461, "text": "NPN\n\n\n#1Resp:\nO: Remains in RA with sats 94-97, RR 40-50, lungs cl=, no\nspells\nA/P: Cont to monitor\n\n#2Parents:\no: Mom and dad and extended family in to visit. Mom held and\nfed.Parents happy with wt gain and progress. Explained to\nparents to sign up for CPR class in preparation for\ndischarge.\nA/P: Cont to support and inform. Discharge teaching\n\n#3FEN:\no: Wt 2255 (+45) On 150cc/k/d SSC 24. Abd.soft, active BS no\nloops . Bottled volume x2. gavages tol well.\nA/P: Cont to offer po QOF\n\n#4G@D:\nO: temps stable in low heat isolette. Infant waking for\nfeeds, alert and active, AFSOF, MAE\nA/P: Cont to support dev.\n\n#6Bili:\nO: Off phototherapy. rebound drawn\nA/P: Check labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-28 00:00:00.000", "description": "Report", "row_id": 1794462, "text": "Neonatology - NNP PRogress Note\n\nInfant is active with good tone. AFOF. She is pink, well perfused, no murmur auscultted. She is tachypneic with mild-mod retractions. Breath sounds sl diminished to bases. Abd soft, active bowel sounds, voiding and stooling. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-28 00:00:00.000", "description": "Report", "row_id": 1794463, "text": "Neonatology\nDoing well. REmains in RA. No spells. No murmur. Pulse pressure slightly widened.\n\nWt up 45. Tolerating feeds at 150 cc/k/d of 24 cal. Abdomen benign.\nWill monitor weight gain on current cals.\n\nBili in 5 range rbd. Will follow clinically.\n\nContinue as at present.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-05 00:00:00.000", "description": "Report", "row_id": 1794500, "text": "PCA Note:\n\n\n#2 : O: Mom called numerous times throughout the day\nand was updated by the NNP and RN. P: Continue to support,\nteach and prepare for discharge.\n\n#3 FEN: O: 130cc/kg SC 24. PO/PG feedings q4h as\ntolerated. Infant bottled this morning and was supplemented\nby gavage. Infant bottled full volume this afternoon. Med.\nspit x1 this morning with a burp. Minimal aspirates.\nInfant's abdomen is soft, nontender, +BS, no loops. Infant\nis voiding, no stool today thus far. A: Infant tolerating\nfeedings well. Infant is well coordinated, gaining stamina.\nP: Continue to support infant's nutritional needs.\n\n#4 DEV: O: Infant remains swaddled in an OAC, maintaining\nstable temps. Infant sleeps well between cares, wakes with\ncares and remains alert and active throughout. Infant calms\nwith her pacifier. A: Developmentally appropriate. P:\nContinue to support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-05 00:00:00.000", "description": "Report", "row_id": 1794501, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\nmild subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n\nupdated Mom by phone.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-05 00:00:00.000", "description": "Report", "row_id": 1794502, "text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; PCA.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-06 00:00:00.000", "description": "Report", "row_id": 1794503, "text": "#2PARENT\nMOM HERE AT 2100. SHE FED BABY AND HANDLED HER WELL. MOM\nCALLED FOR AN UPDATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-25 00:00:00.000", "description": "Report", "row_id": 1794451, "text": "NPN 0700-\n\n\n1. Remains in NC 25-50cc with sats 89-99%. Lungs clear.\nRR 40-70's with mild IC and SC retractions. No A&B's thus\nfar. Cont to wean NC O2 as tolerated.\n\n2. Parents in to visit for 1300 cares. Worked with the\nparents on feeding techniques for . Updated parents\non plan of care. Parents plan to visit every day at 1300\nadnb 2100 cares. Invested parents. Cont to support,\nupdated, and educate parents.\n\n3. TF advanced to 100cc/k/d of SC20= 39cc Q4hr. Able to\nbottle 10cc at 09 and 1300. Infant uncoordianted and tires\neasily. Abd benign. Voiding and one meconium stool thus\nfar. Dstick 65. Plan to advance feed 20cc/k every other\nfeed as per team due next at 2100. Plan to alt. PO/PG feeds\nat this time and monitor tolerance.\n\n4. Infant nested on sheepskin in air isolette. Temps\nstable. Alert and fiesty with cares. MAE, brings hands to\nface. Suckles well on pacifier for comfort. Cont to\npromote G&D.\n\n6. Remains under single phototherapy with eye shields on.\nColor is slightly jaundiced. One meconium stool thus far.\nWorking up on feeds as noted above. Plan to obtain bili on\nwednesday as per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-26 00:00:00.000", "description": "Report", "row_id": 1794452, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS ON NASAL CANNULA 100% FIO2 IN 25-50CC FLOW. 02 SATS >92%. 02 INCREASED SLIGHTLY WITH BOTTLING TO MAINTAIN SATS. BS CL&= WITH MILD-MOD RETRACTIONS BUT NO INCREASE IN WORK OF BREATHING OVER NIGHT. SX'D FOR SMALL SECRETIONS X1.NO A&B'S OR DESATS NOTED TONIGHT. COLOR PALE/PINK AND WELL PERFUSED. BP 56/39-43. REMAINS UNDER SINGLE PHOTOTHERAPY. BILI LEVEL ORDERED FOR .\n\nFEN: WEIGHT DOWN 30GMS TO 2190GMS. TOTAL FLUIDS MAINTAINED AT 100CC/KG/D OF SC20CAL. BOTTLED 10CC FOR MOM AND THEN 25CC WELL AT 0500 WITH CHIN SUPPORT. D-STICK STABLE. ABD SOFT, PINK WITH +BS AND STABLE GIRTH. NO EMESIS OR SIGNIFICANT RESIDUALS.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-26 00:00:00.000", "description": "Report", "row_id": 1794453, "text": "NURSING ADDENDUM\nPLEASE NOTE - INFANT'S TOTAL FLUIDS PRESENTLY AT 120CC/KG/D (NOT 100CC/KG/D) AND WILL ADVANCED TO FULL FEEDS OF 140CC/KG/D AT 0900.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-26 00:00:00.000", "description": "Report", "row_id": 1794454, "text": "Neonatology\nRemains in low flow NCo2. Slightly tachypneic but generally comfortabler appearing. Good air entry bilaterally. No murmur.\n\nWt 2190 down 30. Tolerating feeds at TF at 140 cc/k/d. Mainly gavage. Taking pos as well. Feeds to be increased to 150 cc/k/d as tolerated today.\n\n\nClincially stable off abx.\n\nJaundiced appearing. Under single photorx with bili in range.. Bili to be repeated in am.\n\nCOntinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-26 00:00:00.000", "description": "Report", "row_id": 1794455, "text": "NEonatology-NNP Progress Note\n\nPE: remsins in her isolette in nasal cannula O2, bbs Cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afso, jaundiced, under pt with eye covering on\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2185-07-26 00:00:00.000", "description": "Report", "row_id": 1794456, "text": "1. remains in ~13-25cc flow 100%O2 nasal cannula,\nRR50-70's, sc retractions, BBS clear and equal P: wean O2 as\ntolerated.\n2. Parents here with relatives ~1300, Mom held and fed baby\nP: continue to update and offer support.\n3.TF increased to 150cc/k/d SC20=58cc q4h, took 30cc po for\nMom, abd soft, no loops, active bowel sounds, voiding and\npassing mec stools.\n4. temp stable nested in heated isolette, active and alert\nwith cares, sucking on pacifier.\n6. eyes covered under single phototherapy, color pale pink\nP; check bili in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794436, "text": "NPN 0700-\n\n\n1. Received infant on IMV 22/6 X20 and weaned to current\nsettings of 20/6 X16 after CBG 7.34/52. FiO2 30-40's with\nsats 88-96%. Occassional desats to 80's. Lungs clear. RR\n30-60's with mild IC and SC retractions. Sxn for small\ncloudy secretions. CXR x2 obtained and pnumo mediastinum\nwithout change per team from early this morning. Plan to\nobtain CBG this evening per team. Cont to monitor resp.\nstatus closely and support as needed.\n\n2. Mother in to visit throughout the day. Taught mom how\nto take temp and change diaper. Parents updated by \n, NNP today. Invested, concerned parents. Cont to\nsupport and update parents.\n\n3. TF 100cc/k/d of now D10PN and IL via PIV. NPO. Dstick\n68. 12hr urine output= 3.2cc/k/hr. No stool this shift.\nAbd benign. Lytes and bili obtained, all WNL; see flowsheet\nfor details. Cont to monitor FEN status.\n\n4. Temp stable nested under warmer. Alert, irritable with\ncares. Settles better on belly and with containment.\nSuckles on pacifier at times for comfort. MAE, brings hands\nto face and mouth. Cont to promote G&D.\n\n5. On amp and gent as ordered. CBC and blood cultures\nnegative to date. Cont to monitor closely for s/sx of\ninfection.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-23 00:00:00.000", "description": "Report", "row_id": 1794437, "text": "NPN\n\n\n#1 Infant remains orally intubated--weaned settings during\nthis shift based on several CBG's. Currently on settings of\n17/5 x14 FiO2 30-35%. RR 30-50's with mild ICR/SCR. BS\nclear and equal. Suctioned for mod white secretions. CXR\nwith left lateral decub done.\n\n#2 Mom called and was updated. Parents plan to visit at\n9am.\n\n#3 Infant remains NPO. TF 100cc/k/d of PN(D10) and IL via\nPIV. DS 68. Abd soft, +BS, no loops. AG 23cm. UO\n3.4cc/k/hr x24hrs yesterday. No stool. Wt 2255(-5gms).\n\n#4 Infant nested on sheepskin with stable temp. Infant\nirritable with cares. Settles when placed prone.\n\n#5 Infant remains on ampi and gent. Blood cultures neg to\ndate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-23 00:00:00.000", "description": "Report", "row_id": 1794438, "text": "Respiratory care Note\nPt. began shift on IMV 20/6 R 16. FIO2 has been 30's%. BS clear after sx'ing. Pt. weaned throughout the night and is currently on 17/5 R14. Last cbg was 7.35/45/37/26/0 on 19/5 R 14. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-23 00:00:00.000", "description": "Report", "row_id": 1794439, "text": "Nebworn Med Attending\n\nDOL#3. Extubated this AM. On NC O2 now but may need CPAP. No spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2255 down 5, on 100 cc/kg/d PN/IL.\nA/P: Infant with resolving RDS. need CPAP if WOB increases. D/C abx, as cx -. Increase TF to 120 cc/kg/d. Check bili and lytes in AM.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-03 00:00:00.000", "description": "Report", "row_id": 1794489, "text": "NPN 1900-0700\n\n\n2. PAR: Dad and maternal grandfather in to visit .\nDad took temp and bottled . He asked appropriate\nquestions.\n\n3. F&N: TF remain at 150cc/k/d of SC 24. She bottled\n42cc with Dad at 2100. She woke early for 0100 cares and\nonly bottled 20cc. Abd benign. BS+. No spits and minimal\naspirates noted. Voiding well. No stool noted so far this\nshift. Weight gain 55 grams.\n\n4. DEV: is active and alert during her cares. She\noccasionally wakes early for her feeds. Temp stable\nswaddled in open crib. She sucks on her pacifier and puts\nher fingers to her face.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-03 00:00:00.000", "description": "Report", "row_id": 1794490, "text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable apeparing.\n\nWt 2535 up 35. TF at 150 cc/k/d of 24 cal. Took all po overnight but requriing gavage this am again.\n\nActive alert on exam. Moving all 4.\n\nContinue as at present. Awiaitng maturation of resp contorl and feeds.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-03 00:00:00.000", "description": "Report", "row_id": 1794491, "text": "0700-1900 NPN\n\n\nFEN: TF=150cc/kg/d of SSC24 PO/PG q4hr. Infant offered\nbottle with each feeding. Infant has bottled 5cc and 21cc\nwith fair coordination so far this shift. Abdomen pink,\nsoft, round, +BS, no loops. No spits, no aspirates. Voiding,\nno stool. Continue to monitor FEN status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Independently waking for\nfeeds. Brings hands to face, loves pacifier. Continue to\nsupport G+D.\n\n: Mom called x2, updated by this RN. Continue to\nsupport family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-03 00:00:00.000", "description": "Report", "row_id": 1794492, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. active bowel sound. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794433, "text": "Clinical Nutrition:\nO:\n34 week gestational age BG, AGA, now on DOL 2.\nBirth WT: 2315g(50-75 %ile)\nHC @ birth: 31.5cm(25-50 %ile)\nLN @ birth: 46.5cm(50-75 %ile)\nLabs noted.\nNutrition: TF @ 100cc/kg/day. NPO. D10W ivf's infusing via PIV. Plan to satrt PN today via PIV; Projected intake for next 24hrs from PN ~50kcal/kg/day, ~2g pro/kg/day, & ~1g fat/kg/day. Glucose infusion rate from PN ~6.5mg/kg/min.\nGI: Abd benign.\n\nA/Goals:\nRemains NPO d/t respiratory status. IVF's infusing as above. Plan to initiate PN today via PIV. Initial goal for PN ~90-110kcal/kg/day, ~3.0-3.5g pro/kg/day, & ~3.0g fat/kg/day. Advancing per protocol. Limitations may preclude being able to deliver adequate nutrition frm PN via PIV. When able to start feeds, initial goal is ~150cc/kg/day BM/SSC 24, providing ~120kcal/kg/day & ~3.2-3.3g pro/kg/day. Further advances as per growth & tolerance. Growth goals after initial diuresis are ~15g/kg/day for WT gain, ~0.5-1.0cm/wk for HC gain, & ~1.0cm/wk for LN gain. will follow w/ team 7 participate in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794434, "text": "Resp care\nPt remains intubated & supported w/ mechanical ventilation\nReceived Pt IMV mode 22/6 x 20, Pt tolerated weaning well\nCurrently on IMV mode 20/6 x 16, 30-40%, CBG 7.34/52\nOn a RR of 20, weaned to 16\nRR- 40-60's w/ mild retractions\nB/S clear, sx small amount of cloudy secretions\nPt self extubated, decision made to reintubate\n3rd dose of survanta given, 9.3cc\nPt tolerated well\nPlan: Continue support\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794435, "text": "Neonatology\nNoted to be self extubated this afternoon. Given short trial of facial CPAP. Able to maintain sats in ~ 40-50% fio2, but increased WOB so reintubated with 3.0 ETT after sedation with fentanyl. Bilateral BS. ETT just above carina. NG coiled in espophagus. NG replaced. ETT puleld back slightly. Equal BS on exam. Remains slightlky tachypneic.\n\nCXR before and after intubation shows persistent air leak. Right lung with residual findings of HMD. Given this rxed with thrid dose of surfactant. After surfactant has equal appropriate BS. Good air entry on spontaneous breaths. Vent to be weaned as tolerated by clinical exam and blood gas.\n\nSpoke with mother at bedside and with parents in her postpartum room. Discussed current status and plan of care along with potential need for thoracentesis and/or chest tube placement if persistent or increased air collection.\n" }, { "category": "Nursing/other", "chartdate": "2185-08-04 00:00:00.000", "description": "Report", "row_id": 1794493, "text": "NPN 1900-0700\n\n\n2. PAR: Dad in with maternal grandfather to bottle infant\nat 2100. Mom called for update.\n\n3. F&N: TF remain at 150cc/k/d of SSC24. She bottled 20cc\nwith Dad at 2100 and 35cc at 0100. Abd benign. BS+. No\nspits and minimal aspirates noted. Voiding well and passed\na large green guiac negative stool. No weight change.\n\n4. DEV: is active and alert during cares. Temp\nstable swaddled in open crib. She wakes early for her\nfeeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-04 00:00:00.000", "description": "Report", "row_id": 1794494, "text": "Neonaotlogy-NNP Progress Note\n\nPE: remains in her open crib, in room air. bbs cl=, rrr s1s 2no murmur,a bd sfot, nontneder, full V&S, afso, active with care, gavage tube in place\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2185-08-04 00:00:00.000", "description": "Report", "row_id": 1794495, "text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable apeparing.\n\nWt 2535 without change. Tolerating feeds at 150 cc/k/d of 24 cal.. Abdomen benign. Still erquriing ~ gavage. Took full bottle this am.\n\nActive alert. Moving all 4. SKin w/o leisons.\n\nTemp stable in crib.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794430, "text": "NPN\n\n\n1. Resp: Received infant intubated on 26/6 IMV 30 in 35-40%.\n\nCBG at 24:00-7.33/43, weaned IMV to 25 after receiving 2nd\ndose of survanta at 1am. BBS clear w/mild to mod IC/SC\nretractions, very large air leak heard. Infant irritable at\ntimes and stress intolerant with occ desats, receiving\nfentanyl x1 prior to survanta. Repeat CBG at 5am 7.40/42,\nremaining in 35-40% range. CXR taken with ? pneumo, lateral\nfilm also obtained-pneumo ruled out. Vent settings decreased\nto 22/6 with IMV of 20- after CBG.\nA/P; RDS, s/p survanta x2, able to wean vent settings,\nmonitor resp exam closely-\n\n2.Parenting: Parents at bedside x2, visiting with relatives.\n , worried about baby. called again for update\nduring the night.\nA/P: Appropriately stressed parents, keep well informed and\nupdated-parents wanting to be notified of any changes in her\ncare.\n\n3. FEN: WT 2.260 kg, down 55 gr.\nPIV in left hand infusing D10W w/lytes, 100cc/kg. UOP\n4.3cc/kg/hr. No stools. DS 88 and 92. Abd soft, NPO.\nA/P; Monitor wt and fluid status, remains NPO-mom wants to\nbottle feed.\n\n4. G&D: Stress intolerant, responding to containment and\ndecreased noise. Fentanyl given x1 with fairly good\neffects-prior to survanta administration. Sucking on\npacifier. Nested on warmer, likes prone position.\nA/P; Decrease noxious stimuli, fentanyl as ordered.\n\n5. Infection: On amp and gent, temps 97.8-99. Closely\nmonitor for signs of sepsis.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794431, "text": "Neonatology\nRemains on vent after intubation last night with increasing Fio2 requirement. Received two doses of surfactanct. Most recent CXR shows small right pneumomeiastinum. Continued ability to wean. PIP down from 25 to 20 and rate decreased over recent hours. Maintain clinical and radiologoc monitoring of air leak as needed.\n\nWt 2260 down 55. TF at 100 cc/k/d.A bdomen benign.\nLytes in good range. Will remain NPO this am. Consider start of feed later this afetrnoon. Will begin PN.\n\nBili in 5 range. Will follow\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-22 00:00:00.000", "description": "Report", "row_id": 1794432, "text": "Neonatology NP Note\nPE\nnested on radiant warmer\nAFOF,sutures opposed\nmild-moderate subcostal/intercostal retractions in IMV, tachypnea\nlung with scattered crackles BS equal\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, few bowel sounds\nactive with good tone.\n\nUpdated mother in person and father by phone regarding of changes this am in cxr pneumomediastinum/pneumothorax and possible need for needles thoracentesis and thoracotomy tube.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-24 00:00:00.000", "description": "Report", "row_id": 1794447, "text": "Nursing Progress Note\n\n6 Bili\n\n1. Resp O/A Rec'd inf in NC. Inf remains in NC 100%\n50-125cc thus far. Mild IC/SCR noted. No spells thus far.\nP cont to wean O2 as tol.\n2. Parents O/A Mom and Dad in for visit and cares.\nUpdates given. Mom held infant for 30 minutes. Mom D/C'd\nto home today. P Parents plan to visit tomorrow at 1300,\nwill call periodically for updates.\n3. FEN O/A TF incr today to 140cc/kg/day. IVF currently\nat 80cc/kg/day of PND10 running at 6.7cc/hr, lipids running\nat 1.0cc/hr via PIV. ENt feeds currently at 60cc/kg/day of\nSC20. All feedings PG thus far, tol well. No spits, min\nasp. Belly soft, no loops. Infant is voiding, no stool\nthus far. P Check lytes in AM. Incr ent feeds by\n15cc/kg/day at 0100 and 1300.\n4. DEV O/A is in a low air isolette with stable\ntemp. A/A with cares. Sleeping well between cares. Likes\npacifier. P cont to assess dev needs.\n6. Bili O/A Infant started under single photo TX this AM.\n Eye shields in place. P recheck bili in AM.\nSee flowhsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-25 00:00:00.000", "description": "Report", "row_id": 1794448, "text": "NPN 7p-7a\n\n\n#1 Remains in 25cc of 100% O2 via NC. BBS clear and =. Mild\nretractions present. No bradys or desats thus far in shift.\nA: small O2 need persists P:Follow resp status\n\n#2 Mom and Dad in for 9p care. Mom did diaper change and\ntemp with minimal cuing. Questions answered and complete\nupdate provided. A: involved folks P:Cont to support and\neducate\n\n#3 TF's 140cc/k. IV of PN + IL infiltrated ~ 0100. Order\nwritten to ^ feeds 20cc/k and leave IV out. Infant is\npresently receiving feeds @ 80cc/k=31cc of SC20 q 4hrs on a\npump over 35 mins. No spits or residuals. Abdominal exam\nunremarkable. Voiding. No stool passed yet overnoc. Weight\ndown 20g. A; tolerating advancement thus far P: ^ feeds \n20cc/k., follow tolerance\n\n#4 Temps stable in air isolette. Fiesty with and between\ncares. Nested on sheepskin with boundaries firmly in place.\nLikes pacifier. A: AGA P: support developmental needs\n\n#6 Under single phototherapy. Am bili 12.5/0.4. A:bili level\ndecreasing P: Follow labs\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-02 00:00:00.000", "description": "Report", "row_id": 1794484, "text": "Nursing Progress Note 1900-0700\n\n\nParenting:Mom and grandmother visiting x 2 this shift.Mom\nappeared very tired had D and C done this eve.Cont's very\n and invested.Mom needing with\ncares.Asking appropriate questions.A/P:Cont. to\nupdate,educate,and support.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day.Rec.Similac SC 24\n62cc's alt. po/pg feeds.Infant bottled x 1 and took 40 cc's\nwith a yellow nipple.Weight=2.480kg up 40 grams.Abd. soft\nwith pos bs,no loops or spits,minimal aspirates.Infant\nvoiding and stooling.A:Adequate Weight Gain.Tolerating Feeds\nWell.P:Cont. to assess tolerance of feeds.\n\nG/D:AFSF.Infant appears alert and active with\ncares.MAE.Bringing hands to face and mouth;sucking\nintermitently on pacifier.Infant presently swaddled with\nnested boundaries.Temp. stable.A:AGA P:Cont. to support\ngrowth and dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-08-02 00:00:00.000", "description": "Report", "row_id": 1794485, "text": "NeonatologyDoing wlel. REmains in RA. Comfortable ap\nRA. Comfortable. Spells not problem\n\nWT 2480 up 40. Tolearting feeds at 150 cc/k/d of 24 cal. Abdomen benign.\n\nHearing screen passed bilateral;ly yesterday.\nState lab contact. Initial specimen received.\n\nCOntinue as at present.\n" }, { "category": "Radiology", "chartdate": "2185-07-21 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 835732, "text": " 7:08 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ett placemnt\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n ett placemnt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube placement.\n\n Endotracheal tube is present with its tip in the orifice of the right main\n stem bronchus. The lungs are mildly hyperinflated with a pattern of\n reticulonodular and interstitial opacities. These changes are consistent with\n probable hyaline membrane disease. No evidence of pneumothorax is identified.\n\n IMPRESSION: Right main stem bronchus intubation as described above.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-21 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 835729, "text": " 6:01 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: r/o rds, pneumothorax\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 35 weeks with increasing o2 requirement on cpap\n REASON FOR THIS EXAMINATION:\n r/o rds, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 35-week infant with increasing oxygen requirements.\n\n Since last examination dated , there has been an increase in\n the pattern of interstitial and reticulonodular opacities bilaterally. The\n lungs are hypoinflated. No evidence of pneumothorax is identified.\n\n IMPRESSION: Changes consistent with mild hyaline membrane disease.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-22 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 835820, "text": " 12:18 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: assess pneumomediastinum\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with s/p rds\n REASON FOR THIS EXAMINATION:\n assess pneumomediastinum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post re-intubation; left pneumothorax.\n\n FINDINGS: The cardiac silhouette is normal. There is a left pneumothorax.\n There is mild pulmonary edema, unchanged. The endotracheal tube is 1.0 cm\n above the carina.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-20 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 835587, "text": " 4:50 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: pneumothorax ? surfactant deficiency?\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity at 34 5/7 weeks\n REASON FOR THIS EXAMINATION:\n pneumothorax ? surfactant deficiency?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Day life one film. Infant with prematurity at 34.57 weeks ?\n pneumothorax or Surfactant deficiency.\n\n No prior exams for comparison.\n\n The heart is within normal limits in size. The lung volumes are low. There\n is diffuse opacity of the lung with areas of air bronchograms and small\n granular opacities that in the right clinical setting might represent RDS,\n however a neonatal pneumonia cannot be entirely excluded.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-22 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 835760, "text": " 5:00 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: assess lung vol\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n assess lung vol\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Assess lung volumes.\n\n Endotracheal tube is present with its tip overlying T3 vertebral body. A small\n left medial pneumothorax is present, probably appearing or worsening since\n last examination earlier in the day. Diffuse hazy opacification of both lungs\n with a reticulonodular pattern consistent with hyaline membrane disease.\n Moderate right upper lobe atelectasis.\n\n IMPRESSION: Findings consistent with hyaline membrane disease. Left medial\n pneumothorax as described above.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-22 00:00:00.000", "description": "R BABYGRAM CHEST DECUB ONLY (71035) RIGHT", "row_id": 835761, "text": " 5:29 AM\n BABYGRAM CHEST DECUB ONLY () RIGHT Clip # \n Reason: right side down\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n right side down\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Possible pneumothorax. This is a right-side-down decubitus\n x-ray.\n\n Endotracheal tube is present with its tip overlying C7 vertebral body. A\n probable small pneumothorax is seen in the right hemithorax. Diffuse hazy\n opacification of the lungs with a reticulonodular pattern consistent with\n hyaline membrane disease.\n\n IMPRESSION: Probable left pneumothorax as described above.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-23 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 835875, "text": " 5:14 AM\n BABYGRAM (CHEST ONLY); BABYGRAM CHEST DECUB ONLY () LEFT Clip # \n Reason: evaluate for pneumothorax, please do xrays at 5:00 AM, Also,\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with pneumomediastinum, on vent\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax, please do xrays at 5:00 AM\n Also, left lateral chest decub film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post re-intubation. Left pneumothorax.\n\n FINDINGS: The cardiac silhouette is normal. There is decrease in the left\n pneumothorax. There is pulmonary edema. The endotracheal tube is at the\n carina in one (1) view, and 5 minutes later on the decubitus film it is at the\n thoracic inlet.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-22 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 835844, "text": " 3:44 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: S/p reintubation. Left ptx. Please do AP and lateral film\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n S/p reintubation. Left ptx. Please do AP and lateral film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post re-intubation. Left pneumothorax.\n\n FINDINGS: The cardiac silhouette is normal. There is a left pneumothorax\n unchanged. There is pulmonary edema. The distal endotracheal tube is 0.5 cm\n from the carina. There are two (2) feeding tubs, one (1) coiled at the\n thoracic inlet and one (1) coiled in the distal esophagus. The visualized\n bowel gas pattern is normal.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-23 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 835904, "text": " 4:01 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: assess resolving pneumo, confirm feeding tube in stomach\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n assess resolving pneumo\n confirm feeding tube in stomach\n ______________________________________________________________________________\n FINAL REPORT\n TIME OF EXAM: 16:19 on .\n\n CLINICAL HISTORY: This newborn is on day of life #4 and has had a history of\n bilateral pneumothoraces. An NG tube was recently placed.\n\n FINDINGS: A single portable view of the abdomen was obtained and is compared\n to the chest x-ray dated at 5:35 am.\n\n The ET tube has been removed. The ng tube tip is in the left sided stomach.\n The heart size is within range of normal limits. There is a bilateral, coarse\n opacification of the lungs without focal lung collapse. The bilateral\n pneumothoraces seen on the previous film are now much smaller. The bowel gas\n pattern is normal.\n\n" } ]

[ { "category": "Echo", "chartdate": "2196-09-20 00:00:00.000", "description": "Report", "row_id": 79341, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 94\nBSA (m2): 1.36 m2\nBP (mm Hg): 133/92\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 10:44\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. Dynamic interatrial septum.\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. 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. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Based on AHA endocarditis prophylaxis recommendations, the echo\nfindings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. 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. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is an anterior space which most\nlikely represents a fat pad.\n\nIMPRESSION:Preserved global and regional biventricular systolic function. Mild\nmitral regurgitation with thickened mitral leaflets. Mild pulmonary artery\nsystolic hypertension.\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": "Nursing/other", "chartdate": "2196-09-24 00:00:00.000", "description": "Report", "row_id": 1363279, "text": "ccu nursing progress note\ns: \"i'd like to live to see another day\"\n \"i'd take all the pills if my family was here\"\no: pls see carevue flowsheet for complete vs/data/events\ncv: periods of raf/aflutter today. each episode broke spon. however during episodes of hr to 140 and bp ^ w agitation pt did have some c/o cp. was on dilt gtt which was dc'd once amiodarone gtt started. rec'd 150mg bolus around 4pm, now on 1mg/min gtt to decrease to .5mg/min at 10:30pm. heparin at 900units/hr. ptt sent at 6pm.\npt uncooperative w meds. rec'd asa, 200mg of toprol(was ordered for 400mg) and imdur 30mg over the course of the day.\nresp: no distress. rr 16-24. no o2.\ngi: poor appetite w afternoon meals, did best w breakfast. no stool.\ngu: foley w good uop.\nms: ox2-3. paranoid, restless. picking at hands, sheets. constantly holding denture cup and soft call bell. agitated at times, calling out. was only temporarily reassured w talking w sisters and by phone. nieces and visited but pt did not believe they were her real nieces \"my nieces are much prettier girls!\". able to remember rn's name and other factual details of day. cooperative at times(replacing ivs) but stalls and negotiates w meds, meals, adls, getting oob. has not slept at all. still talking about wish to not have cabg and be able to rehab p hip surgery and get home as soon as possible.\nskin: removed duoderm on coccyx as this was rolling off and not covering pink area. enc pt side to side as tol. dsg intact to r hip.\nsocial: spoke w sisters. nieces visited and updated by dr . will further discuss pt wishes and goals of care in meeting w family tomorrow per dr .\na: raf, cad. htn. alt ms.\np: follow hr/rhythm/bp. assess for ischemia/chf. safety precautions. enc po intake, meds, activity as tol. skin care. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-25 00:00:00.000", "description": "Report", "row_id": 1363280, "text": "CCU NPN\nS:\" Don't try and get rid of my body...You are keeping me away from my family..I need my family.\"\nO: See vs/objective data per care vue. Low grade temp.\nHr 60-80's sr with rare/occ pac's, bp 120-150's/70-mid 80's. Conts on amiodarone gtt at .5mg/min, decreased from 1mg/min with no further afib/flutter. ^ heparin gtt to 1000 units/hr with therapeutic ptt. Was able to get her to take the rest of her lopressor xl therefore held all lopressor iv.\nLungs with diminshed aeration in bases otherwise clear. No o2 with sats 95%.\nFoley drng clear yellow urine. Taking small amts of po's. No bm.\nPt very cooperative initially. She is alert and oriented x3. Taking a few meds at a time, then saying that was enough. Approx 3am became agitated/paranoid, thinking we were keeping her family from her. Intern in to see pt. Able to reassure her that we would call her family at a more appropriate time. Slept only in naps tonight.\nA: awaiting cabg\n ms changes\n no further afib/flutter on amio\nP: cont to reassure pt of surroundings.\n follow rhythm\n" }, { "category": "Nursing/other", "chartdate": "2196-09-22 00:00:00.000", "description": "Report", "row_id": 1363274, "text": "PT REORIENTED WHEN FAMILY ARRIVED,TOOK PO LOPRESSER C DRAMATIC IMPROVEMENT IN HTN.SITTER ORDERED FOR NIGHTS IF PT BECOMES CONFUSED ,PO ZYPREXIA ORDER AVAILABLE.\n\nIABP SUCCESSFULLY DC, NO BLEEDING OR HEMATOMA,DISTAL PULSES BY DOPPLER HEPARIN TO BE RESTARTED IN 6 HRS,11PM 800U NO BOLLUS ,GOAL PTT 60 TO 80.NITRO DC, BP 129/85 .ATTEMPTED TO WEAN DILTIAZEM ,PT NOW IN AFLUTTER ,RATE 69 TO 130.TITRATED BACK TO 15 MICS. PO DITIAZEM 60 MG GIVEN ,WILL ATTEMPT TO WEAN LATER TONIGHT.NEED TO RECHECK LYTES . CT SX DISCUSSED PLAN C PT AND FAMILY ,NEED REHAB FROM HIP SX FIRST AS USE OF WALKER WOULD CAUSE STERNAL INJURY POST OP .\n\nSAT 96 RM AIR BS DECREASED\n\nPOOR APPETITE AT DINNER ,NO STOOL.\n\nAUTODIURESING ,IF URINES DWINDLE REEVALUATE FOR DIURETIC .\n\nBS 166 ON SSRI\n\nT 98,8 P TYLENOL\n\nSTABLE IN AFLUTTER POST IABP REMOVAL ,NOT CONFUSED AT PRESENT BUT AT RISK TO BE\n\nFOLLOW LYTES\nWEAN DILTIAZEM DRIP AS TOL\nRESTART HEPARIN AS ORDERED\nMONITOR FOR BLEEDING\nTURN WHEN ABLE C LEG SPLINT\n" }, { "category": "Nursing/other", "chartdate": "2196-09-23 00:00:00.000", "description": "Report", "row_id": 1363275, "text": "CCU NPN 1900-0700\nS/O:\nafeb. contin. on cefazolin IV. s/p temp spike . BC pnd, urine neg.\n\n- CV: converted to NSR ~ 8pm. 70's SR. no VEA. occas. PAC's. dilt gtt weaned to off by 2300. dilt 60mg po and lopressor 125mg po contin. and tol. well. BP 108/62 - 127/51.\nheparin gtt restarted at 2300- 800u/hr. K+ 3.9- repleted with 40mea po.\n\nleft fem. site D/I. pulses palp/doppler. extrem. warm.\n\nu/o 80-100cc/hr. neg 600cc for . neg. 1.3L LOS.\n\nresp: LS diminished bases. RR 16-24. sats 92-96% on RA. while asleep having periods of apnea 10-20sec. sats stable.\n\nneuro: in eve, pt. awake, alert but appearing slightly confused. able to answer simple questions, but becoming overwhelmed with more complicated questions/instuction. cooperative and pleasant. no sign of agitation. taking all meds with assist. given olanzapine at 2300 with good effect. slept well.\n\nright hip surgical site with intact DSD. 3 skin tears on right hip/upper leg with adaptic/DSD intact. duoderm on coccyx intact. per report, area is pink- no breakdown. heels intact.\npt. turning with abductor pillow between legs. turn/positioned q4hr, tol. well.\n\nFS 120's, no coverage. small amt.of custard in eve.\n\nA/P: stable night, coverted to NSR on dilt gtt. now weaned off, on po dilt/lopressor. BP stable off TNG.\ngood u/o. no O2 requirment. pt. making up for sleep tonight- stable neuro status - taking meds, cooperative. olanzapine for sleep.\n- ? tranfer to floor today? contin. CV meds, follow lytes, enc. increase po/nutrition.\northo following for any dsg changes. PT working with pt.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-22 00:00:00.000", "description": "Report", "row_id": 1363271, "text": "CCU NPN 2300-0700\nS: \" I can't sleep \"\nO: afeb. contin. on cefazolin IV. Cultures pnd so far. urine neg.\nremains on IABP 1:1. MAPS 100-119. painfree. good augmentation.\nsyst. unloading , diast. unloading .\n\nTNG 3.7mcq/k/min. heparin 800u/hr. DIlt gtt 10mg/hr.\nlopressor 100mg given at 12am. no change in HR noted. HO aware. Did not wean TNG gtt tonight. contin. with elevated MAPS although improved since admit.\n\nleft fem. IABP site D/I. pulses doppler to 2+ bilat. feet warm. denies pain in extrem.\n\nu/o 60-100cc/hr. (+) 170 for . neg. 500 LOS. denies SOB.\nSats 92-96% on RA.\n\nNPO after MN for possible surgery today. . to reassess today. pt. aware.\n\nalert. lucid early on but having periods of confusion on/off during night. thought she heard family in nurse station. talking about being mad at her family. confused to time. did not sleep. no agitation. cooperative with staff. taking all meds. tylenol x1\n\nskin: right hip . dsg D/I. 3 skin tears on right hip covered with adaptic/DSD are D/I. coccyx duoderm intact. heels elevated off bed as much as possible.\nFS 185 at 11pm. SSRI.\n\nA/P: titrating up Beta blocker. contin. to require dilt/tng gtt.\nfollow plan for potential surgery. cultures pnd.\nmay postpone surgery another day. monitor pt. for confusion. IABP support. tylenol prn for fever/comfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-22 00:00:00.000", "description": "Report", "row_id": 1363272, "text": "Addendum\nS: \" I have to get out of here \"\n \" I'm not having any surgery \" Get away from me\nO: 0530-0600: pt. calling out, yelling for help. trying to sit up and stating that she had to get out. able to state name/place/date but also agitated, angry, paranoid. refusing meds, labs, etc.\ncalled sister but pt. refusing to speak with her-\nhad MD speak with pt. and currently she is calmer. allowing FS at 0700.\ndiscussed with Dr. need for sleeping med for tonight.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-22 00:00:00.000", "description": "Report", "row_id": 1363273, "text": "84 YR OLD SP FX HIP REPAIR .C/B CP,NEG TRAPONIN .CATH SHOWED 3VD C LM DZ .EF 55%. HX HBP.\n\nPT PARANOID REFUSING MEDS AND RX.FAMILY CALLED BUT PT DID NOT BELEIVE IT WAS HER SISTER ON THE PHONE .PT TRYING TO SIT UP ,REQUIRES CONSTANT FOR PT .AWAITING FAMILYS ARRIVAL TO HELP CALM PT AND GAIN HER COOPERATION.\n\nSR TO ST C FREQUENT PACS HR 90 TO 130.NO RUNS OF AFIB SINCE YESTERDAY. DILTIAZEM DRIP INCREASED FROM 10 TO 15 MG .PT REFUSING PO LOPRESSER.MAP 110 TO 130,IV NITRO INCREASED TO 4 MIC PER KG .IABP WEANED TO 1TO 2 .NO BLEEDING FROM L FEMORAL SITE .PEDALS BY DOP .MG TO BE REPLETED .HEPARIN 800U ,PTT 70 DC 1345.\n\nSAT 96 RM AIR .REFUSES TO ALLOW PHYSICAL ASSESSMENT .\n\nPT EATING LIGHT DIET, NO CO NAUSEA .\n\nHUO 80 TO 240 CL YEL URINE .\n\nT MAX 100.1 ,CX PENDING ,ON ANTIBX.\n\nBS 185 ,REFUSES SSRI COVERAGE.\n\nPT REFUSING RX,HYPERTENSIVE ,TOL IABP 1TO 2 .PLAN TO DC PUMP TODAY .\n\nWORK WITH FAMILY TO REORIENT PT AND GAIN HER COOPERATION\nWEAN NITRO THEN DILTIAZEM DRIP WHEN TAKING PO .\nSITTER FOR NIGHT SHIFT .\n NEED HALDOL ,HAVE HO EVAL TONIGHT .\n" }, { "category": "Nursing/other", "chartdate": "2196-09-21 00:00:00.000", "description": "Report", "row_id": 1363269, "text": "84 YR. OLD WOMAN WITH PMH HBP & MACULAR DEGENERATION, ADMITTED TO OSH S/P FALL & FX TO R. HIP. SURGICAL REPAIR C/B POST-OP CP WITH\nGLOBALST CHANGES. TROPONIN(-). ->TRANSFERRED TO CATH LAB->\nSEVERE 3VD INCLUDING L. MAIN. IABP PLACED. ECHO DONE AT OSH 55%.\n\nNEURO: A&O X3 PLEASANT & COOPERATIVE.\n\nRESP: O2->3L NP. BS CLEAR. RR 14-22. O2 SAT 96-100%.\n\nCARDIAC: CHANGE OF SHIFT PT CONVERTED TO AFIB/AFLUTTER WITH PVC'S. TX WITH LOPRESSOR 5MG VP X3. ~2130 HR 70-80'S. ~0100 HR BACK UP TO 130-150 AFLUTTER. DILT BOLUS 20MG VP X1 FOLLOWED BY DILT GTT. HR BRIEFLY 80 THEN UP TO 120'S. RE-BOLUSED X1, & GTT TITRATED UP FOR HR 60-80. PRESENTLY INFUSING AT 15MG/HR. HEPARIN GTT INFUSING AT 800U/HR. PTT 65.2. NTG GTT ON/OFF--PRESENTLY AT 1.5MCG/KG. BP 109-160/70-94.\nIABP 1:1. POOR AUGMENTATION. SYSTOLIC UNLOADING . TRANSFUSED 1U PRBC FOR HCT 28.7->POST-TRANSFUSION HCT 30.6. K 3.7->KCL 40 MEQ PO X2.\nSEEN BY CTSURG & OR CONSENT SIGNED. NPO AFTER MIDNOC FOR OR. DENIES CP/SOB. L. GROIN SITE C&D. +BPPP.\n\nGI: ABD. SOFT. BS+. NO STOOL. NPO FOR SURGERY.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 100-525. BUN/\nCREAT 8/0.6.\n\nID: T(MAX) 100(PO). URINE & BLOOD CX PENDING.\n\nENDO: BS 140'S. NO TX NEEDED.\n\nAM LABS: WBC 10.3, HCT 30.6, PLAT 156K, PT 14.1, PTT 50.5, INR 1.3,\nK 4.6, BUN/CREAT 9/0.6, MG 2.0.\n\nPLAN: NPO->OR CABG 2nd CASE.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-21 00:00:00.000", "description": "Report", "row_id": 1363270, "text": "CCU NPN\nS: \"I've eaten all I can\"\nO: please see carevue for all objective data.\nneuro: alert, oriented x3, very pleasant, cooperative w/ care.\ncv: A fib 96-107, converted to nsr at 1000 w/ rate 79-90, w/ occ apc's. Remains with iabp support 1:1, MAPS 98-133, fair unloading and augmentation. L groin site d/i. distal pulses palpable/dopplerable. nl CSM. Dilt gtt 15 mg/hr-> 10 mg/hr, NTG 1.5 mcg/kg/min -> .5 mcg/kg/min. heparin at 800units/hr w/ theraputic ptt.\nresp: SATS 94 % on RA, lungs CTA\ngi: poor appitite, + bs, no BM\ngu: foley draining CYU, 35-160cc/hr, currently ~ 300cc neg since mn.\nid: tm 101.5 R at 1000, wbc 11.8 at 1700. Continues on cefazolin\nend: bs 180-188 covered per sliding scale\nheme: hct stable at 32\nskin: r hip w/ 3 areas of skin abrasion, all with pink base, cleaned w/ wound cleaner, covered w/ adaptix and dsd. Incision from hip repair well approximated, d/i. duoderm on coccyx intact, reddened but not broken down. r hip to have no extension, adduction or external rotation. Hip pain only when turning.\nsocial: sisters and in to visit in afternoon, updated on POC.\nA: CABG postponed d/t ^ temp\n converted to sr, tolerated decrease in dilt and ntg.\nP: Monitor temp curve, ? CABG \n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-20 00:00:00.000", "description": "Report", "row_id": 1363267, "text": "CCU Addendum\n0600: pt. becoming more angry, wanting to go back to hospital....confused to place/time, trying to sit up. as stated above note, pt. was awake all night- now with confusion. Dr. spoke with pt. - assisted pt. to call sister at 0630. pt. spoke with sister who is coming in late AM today. pt. appears more calm now at 0630- although she is refusing any further meds.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-27 00:00:00.000", "description": "Report", "row_id": 1363284, "text": "CCU NPN 1900-0700\nS: \" Get my sister over there \"\nO: pt. confused. knows self only. awake most of night. took po zyprexa in eve with much encouragement. becomes more agitated when spoken to, cannot hold lucid conversation. confused with simple questions. picking at IV's but did not try to remove. trying to get OOB/sit up.\n\nHR 69-87 SR. no VEA. occas. PAC's. heparin restarted intially at 500u/hr, increased to 900u/hr per order. TNG gtt unchanged at 1.88mcq/k/min. no C/O CP.\n\nSats 95-96% on RA.\n\nfoley draining 60-70cc/hr. positive 1L for .\n\nGI: difficulty feeding self, spilling juice. no stool.\nSKin: coccyx pink. pt. resisting turning/repositioning. refusing much care. right hip surgical dsg D/I. area of eccymosis seen around site.\n\nA/O: contin. acute confuion/delerium during night, refusing/resisting care, meds. no CP.\n- zyprexa per geriatric consult. safety measures, sitter as needed. OOB today. encourage po's/nutrition.\n- contin. TNG for BP control and Heparin gtt for Af/flutter.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-20 00:00:00.000", "description": "Report", "row_id": 1363268, "text": "CCU NPN\nS: \"I'm going to have my surgery tomorrow\"\nO: Please see carevue for all objective data\nneuro: alert, oriented x2. occasionally confused, and hallucinating, saying she is seeing people standing upside down. Cooperative w/ care.\ncv:Pain free. remains w/ 30cc IABP, 1:1. MAPS 93-147. hr 73-102 sr w/ occ-freq PVC's. Lopressor increased to 75 mg TID, captopril ^ to 12.5 mg tid. NTG remains at 3.29 mcg/kg/min. PTT 35.6, heparin bolused 1200units and gtt ^ to 800units/hr at 1400. distal pulses weakly palpabable. r groin w/ iabp d/i. ECHO done, results pnd. carotid US done L-> 40-59%, R 40%. NP in to speak to pt and family re: CABG.\nresp: lungs CTA, sats 96-99% on 3l np\ngi: poor appitite, no stool + BS\ngu: foley draining CYU 70-200cc/hr, ~ even since mn.\nid: temp spike to 102 rectally at 1600, bc x2, urine cx sent. given 650 mg tylenol. down to 99.8 orally at 1730. wbc 8.2\nheme: hct down to 28.4 down from 31, currently receiving 1 unit prbc.\nskin: R hip w/ 2 skin tears, covered w/ adaptix, r hip incision intact.\nsocial: sisters and , grandson in to visit. They met w/ MD and NP and are aware of plan.\nA: ? CABG in am, HO to inform team of temp spike.\n poor BP control\n\nP: monitor temp, follow MAPS, ^ cv meds per team. f/u hct post tx, PTT, labs .\n" }, { "category": "Nursing/other", "chartdate": "2196-09-27 00:00:00.000", "description": "Report", "row_id": 1363285, "text": "CCU NPN\nS: \"Get those people out of here, I don't want them watching me\"\nO: please see carevue for all objective data\nneuro: alert, oriented x2. Continues to be very suspicious, paranoic. Confused at times. This am agitated, trying to standup, wanting to go home, get dressed. Zyprexa ^ to 5 mg , much calmer this afternoon, more cooperative, although still suspicious. Taking most of her meds, with much encouragement.\ncv: hemodynamically stable. Heparin ^ to 1100 units/hr , and given 500unit bolus at 1700, d/t subtheraputic ptt. started on NTG patch, iv d/c.\nresp: sats 95-97% on RA, lung sounds diminished\ngi: mod, brn stool ob-, appitite slightly improved, needs help eating and encouragement.\ngu: foley draining cyu qs\nid: afebrile\nactivity: OOB to chair w/ 2 assists, tolerated well. to chair ~ 4-5 hrs.\nskin: coccyx reddened. surgical incision d/i, ecchymotic.\nsocial: sisters in to visit.\nA: slightly improved ms w/ ^ zyprexa. tolerating ^ activity.\nhemodynamically stable, PF\nP: monitor response to ^ zyprexa, continue ^ activity, PT, encourage po intake. screen for rehab.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-28 00:00:00.000", "description": "Report", "row_id": 1363286, "text": "CCU NPN 1900-0700\nS/O:\nTM 98.6AX. WBC 11.4(12.5 ). ? of UTI: foley was d/c'd and given cipro IV x1dose. still need UA when pt. voids.\n\nCV: HR 62-70 SR. no VEA. rare PAC. BP 120-170's/60-80. off TNG. heparin for coagulation with Hx Afib/flutter. Heparin at 1100u/hr with AM PTT 100.2-> decreased to 1000u/hr at 0500.\n- AM K+ 3.2- ordered for KCL 40meq/500cc over 4hours.\n\ndenies CP.\n\nResp: LS clear to diminished. RA sats 93-95%.\nGU: foley removed d/t possible UTI. Has not voided since 12am when removed.\nneuro: pt. sleeping - waking up when stimulated with turning, blood draws etc. no agitation. able to state name but did not know place/time. cooperative, took zyprexa 5mg at 2300. slept through night. too sleepy to take anything else by mouth. HO aware.\nplan to decrease zyprexa dose back to 2.5 with extra PRN dose for nighttime.\nskin: right surgical hip site with approx. staples. no drainage. area cleansed with NS and DSD replaced.\n- small skin tear on right hip near surgical site pink, no drainage. NS/adaptic/DSD.\n\nA/P: potential UTI- foley out and DTV. cipro x1.\n- slept well, more cooperative. will discuss lower zyprexa dose during day.\n- plan to D/C to rehab- in process\n" }, { "category": "Nursing/other", "chartdate": "2196-09-20 00:00:00.000", "description": "Report", "row_id": 1363266, "text": "CCU NPN 1900-0900\nS: \" You're trying to make me out like the crazy one \"\n \" I'm not taking anymore pills, thankyou. I'm feeling fuzzy \"\n\nO: pt. not sleeping at all. given 1mg IV morphine at 2130 for c/o general discomfort with good effect. dozed for short time following that but has been awake since. A/O x3 but becoming slightly more antagonistic and restless at times during night. took 12am meds with much encouragement and refusing any further during the night. HO aware.\nno further c/o pain. refusing any further pain meds, including tylenol stating that she was feeling fuzzy in the head. tolerated turning well with 2 assist. abducter foam pillow in place with legs strapped in loosely.\n0430: asking for something to eat. given toast/juice- tol. well.\n\nCV: HR initially 75-80's SR. no VEA. started on lopressor 25mg PO , first dose at . given additional 25mg po at MN for HR 80-90SR with little effect. HO aware. HR elevated to 90's at times. unclear if related also to mood, wakefullness. given IV lopressor 10mg x1 at 0330 : HR coming down to 70's when calm.\nK+ 3.1 on admit to CCU . given total 80meq po between 2100-2300.\nMG+ 1.9- 2gms IV x1. AM labs pnd at 0400.\n\nMAPS 113-130. TNG at 3.29mcq/k/min. started captopril 6.25mg at MN. MAP remains elevated >100. HO aware. pt. denies CP/SOB. admit CPK 152/2.\nHCT 31.6. clot in BB. Heparin started at 550u/hr and then decreased to 500u/hr per orders. AM PTT pnd.\n\npost cath fluids .45NS at 100cc/hr continues x1L\n\nIABP at 1:1. sharp waveform. poor augmentation. systolic unloading 0-22pt.s left fem. site D/I. pulses palp. and extrem. warm bilat.\n\nResp: LS clear. 3lnc sats 98-99%.\nGU: foley draining 80-100cc/hr. neg. 300 since arriving to CCU.\nGI: pos. BS. no stool since surgery per pt. but is passing flatus.\ntaking meds/pills with water/juice. custard in eve and toast at 0500.\nendo: FS 172 at MN- 2U humulog. pt. needing extra reasurance and explanation concerning new QID FS and insulin coverage while in ICU.\n\nskin: right hip wound dsg is D/I. has 3 skin tears surouding the hip dsg covered with adaptic/DSD. not observed but described as pink skin abrasions by previous RN.\n\nA: lack of sleep puts pt. at higher risk/potential for confusion/restlessness\n - HR/MAP not ideal. pt. refusing po meds at this time. HO aware and will address in AM. IV lopressor x1.\n\nP: follow MS closely. hold any further morphine.\ncontin IABP/plan for surgery. pt. stating that she is planning on calling her sister today to come in. she will speak to her siblings about surgery.\n- monitor lytes, PTT. CK, HCT.\nabductor pillow at all times. monitor wound dsg for change. freq. turning as tolerated\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-25 00:00:00.000", "description": "Report", "row_id": 1363281, "text": "ccu nursing progress note\ns: \"i feel a little light headed\"\no: pls see carevue flowsheet for complete vs/data/events\noob this am, heavy assist of 2 to take a few steps/pivot to chair /commode. pt tol well. sat at edge of bed indep for sev minutes w cuing to use arms for support.\npt very hypertensive all morning. bp 160-190/70-80. hr 65-80 sr. rec'd imdur, amiodarone and asa in am. remained on amio gtt at .5mg and heparin at 1000units/hr. shortly after returning to ch from commode pt's family called rn to room b/c of her change in breathing. pt found in sitting position, head back. shallow breathing. pale, damp skin. hr 60s. nbp cycled 70/50, pt initially unresponsive. lifted back to bed. started to respond, c/o feeling lightheaded. denied cp/sob. hr 60-70s sr w bp 140-170/60-70. ms slowly returned to baseline and no further symptoms. ekg without changes. started iv ntg for htn. added lisinopril. no further episodes this shift.\niv amiodarone dc'd as pt took oral dose. had brief episode of raf/aflutter today lasting approx 10-15min.\nheparin at 1000units/hr w am ptt 62.\n\nresp: no distress. ra sat 93-95%. on 2l nc sat >98%. basilar cxs.\ngi: fair appetitie today. no bm despite attempt on commode.\ngu: foley w fair uop. cr stable.\nskin: stage 1 coccyx breakdown. skin care given and enc off buttucks.\nsocial: healthcare proxy is pt's neice according to family. , sister and mother (pt's sister) had long meeting w ccu team(resident and intern) to discuss goals and plan of care as well as rec update. family appears to be of mind that cabg would not be the option would want d/t high risk and long, complicated rehab. will discuss further w other family members and communicate their decision to the team tomorrow( and plan to visit tomorrow) regarding proceeding w surgery or opting for medical management.\nms: had many visitors today. confused at times but generally more cooperative.\na: episode of extreme hypotension and loc ?r/t orthostatic hypotension per team. resolved spon. cad, usa.\np: follow bp, titrate ntg. monitor rhythm. assess for ischemia/chf. enc nutrition. skin care. safety precautions. support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-24 00:00:00.000", "description": "Report", "row_id": 1363278, "text": "84 YR. OLD WOMAN WITH H/O HTN & MACULAR DEGENERATION--S/P FX HIP .\n->REPAIR FX R. HIP AT OSH. POST-OP CP WITH GLOBAL ST CHANGES. (-)\nTROPONIN. ->TRANSFERRED CATH LAB->3VD INCLUDING L. MAIN->\nIABP. SEEN BY CTSURG--WAS TO GO TO OR FOR CABG, BUT CANCELLED D/T\nSPIKED T 102(URINE & BC -) & ARRYTHMIA(FIB/FLUTTER). TREATED WITH IV\nMETOPROLOL & DILT GTT. NOW PT IS HAVING PERIODS OF CONFUSION & HALLUCINATIONS--REFUSING ALL NURSING CARE(TEMPS, BLOOD WORK, MEDS).\nATTEMPTED TO BITE THIS NURSE WHILE TRYING TO NURSING CARE.\nHALDOL .5MG IV X1 WITH LITTLE EFFECT. PT WANTS TO GO TO HOSPITAL REHAB FOR HIP & *MAYBE* HAVE CABG AT LATER DATE.\n\nNEURO: AS STATED ABOVE, PERIODS OF HALLUCINATIONS & HOSTILITY. CHANTING \"PLEASE SEND ME HOME. I WANT TO GO HOME.\" REFUSING ALL NURSING CARE.\n\nRESP: BS CLEAR BUT DIMINISHED AT BASES. RR 17-25. O2 SAT 97-99% ON RM. AIR.\n\nCARDIAC: HR 108-115 ST, NO ECTOPY. BP 154-175/73-102. REFUSING CARDIAC MEDS. NTG GTT RESTARTED 1->3 MCG/KG. ~0130->HR 180 AF/FLUTTER. METOPROLOL 5MG VP X2. BOLUSED WITH DILT 20MG X2 & DILT GTT 5MG->10MG.\nHR 100-130'S ST/AF.\n\nGI: REFUSING DIET. SIPS CL. LIXS OCCASIONALLY. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW/AMBER URINE. U/O 15-60CC/HR.\n\nID: REFUSING TEMP.\n\nAM LABS: REFUSED.\n\nPLAN: CT STILL WANT PT TO HAVE CABG, PT DOES NOT WANT SURGERY AT THIS TIME--??COMPETENCY. PSYCH NURSE SAW PT & RECOMMENDS FULL PSYCH EVAL WHICH WOULD BE HELPFUL TO FAMILY IN DETERMINING WHAT IS RIGHT FOR PT.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-26 00:00:00.000", "description": "Report", "row_id": 1363282, "text": "CCU NPN\nS: \" Get my sisters...they are right over there.\"\nO: See vs/objective data per carevue.\nHr 70-80's sr with rare/occ pac, also with a couple of episodes of self-terminating afib/flutter lasting approx 10-30secs long. Heparin conts at 1000 units/hr (hct 26.7). Ntg titrated to keep bp < 140, currently at 1.878mcg/kg/min, with bp ranging 110-130's. ^^ bp with agitation that occurred early in shift.\nRemains on room air with sats in the mid 90's.\nFoley drng conc yellow urine. Rec'd a 250cc ns bolus with mild increase in urine output. No bm.\nVery agitated initially, telling nurse no to all questions asked, saying that I was wasting my time. Then becoming increasingly agitated, team aware. Pulling off leads attempting to get oob. Rec'd total of 1.5mg haldol and 2.5mg zyprexa with excellent results. Slept most of night with no further agitation. This am seems to be cooperative stating that she feels fine but she is disoriented to place.\nA: agitation resolving with zyprexa and haldol\n ^^ bp titrating ivntg\n short episodes of afib/flutter resolving on own\nP: cont to increase activity as tol\n cont to reorient as needed\n to receive increase dose of lisinopril today\n recheck hct\n" }, { "category": "Nursing/other", "chartdate": "2196-09-26 00:00:00.000", "description": "Report", "row_id": 1363283, "text": "ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\ns: later dear, not now(taking pills)\no: id: afeb. no abx.\ncv: sr hr 70-90s, freq apcs. a few brief episodes of aflutter, self limiting. bp 140-180/50-70 via nbp. ^'d lisinopril dose to 20mg. rec'd 400mg toprol. remains on iv ntg, oral imdur held.\nptt 71 on 1000units of heparin.\nk 3.6. started iv kcl 40meq in 500cc to infuse over 4hrs.\nresp: no sob. sats 95-97% on ra. rr mid 20s, nonlabored.\ngi: good appetite at dinner w family present. had lrg formed stool, ob neg after dinner.\ngu: foley to w uop 30-50cc/hr. +800cc since mn.\nskin: coccyx reddened, intact. r hip w ^ edema and ecchymosis as compared w yesterday. team aware. sm amt serous drg from wound. ct revealed hematoma this eve. heparin now being held as of 5:30pm and surgery to consult.\nhct 26 this am, repeat 28(32 ). rec'd 1unit prbcs. i hr post hct 33.\nsocial: sisters and visited. pt much better w family present. cooperative, takes meds. met w dr and briefly w dr . family discussed w pt after meeting and all have concluded to decline cabg and pursue rehab and medical management.\nms: most of day periods of confusion. uncooperative w adls, taking meds, eating. having hallucinations at times. better this afternoon, taking pills w family encouragement. geriatrics consulted.\noob w 2 assist. did exercises w PT. case manager aware of plan for rehab on ss. will begin process when pt closer to medically ready.\na: htn w noncompliance w meds. hct up s/p tranfusion of 1 unit prbcs. hematoma into r hip s/p ^activity this past 2 days on heparin.\np: follow hemodynamics. assess r hip. ortho to consult. bedrest for now. safety precautions. reorient prn. support to pt and family. dc planning.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-23 00:00:00.000", "description": "Report", "row_id": 1363276, "text": "addendum:\npt. woken up for 6am meds at 0530. given po dilt dose and labs drawn. A/O x2 at the time with no c/o. 0550: c/o CP- mid sternal. unable to number. BP 140's/60's, HR 95ST. sat 92% on RA. did not appear in distress. IV tng started at 2mcq/k/min. given total 10mg IV lopressor. EKG with Ant. ST depressions. painfree by 0605. post EKG more toward baseline. HR down to 78Sr/BP 116/60 at 0630. weaning TNG GTT. HO/resident present.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-23 00:00:00.000", "description": "Report", "row_id": 1363277, "text": "CCU NPN\nS: \" Those aren't my teeth...\", \"No pills, no shots, don't touch me\"\nO: please see carevue for all objective data\nneuro: pt alert, oriented to name, time, place, however has been paranoid, and very suspicious all day. Has refused all medication, all treatments. Agitated only when approached to give meds, or treatment, of left alone calm. At times calling out for brother and sister in law. At times believes sister in the room isn't the \"real \" Seen by , psych RN for med recommendations. Plan to give Zyprexa 2.5 mg or Haldol .5 mg iv.\ncv: hr 85-107 sr w/ frequent apc's. bp 136-176/57-77. continues on NTG 1 mcg/kg/min, heparin at 800units/hr. lopressor changed to 400 mg metoperol XL, only able to convince pt to take 200mg. started on imdur, but pt refused, so ntg continues. Refused diltiazem.\nNo c/o cp\nresp: SATS 96-99% on RA\ngi: refusing all food except few sips soup, few bites of peaches. No stool\ngu: foley draining CYU, qs.\nid: temp 99 this am refusing since\nheme: hct stable\nactivity: PT here to begin exercises and hip rehab, pt refused.\nsocial: sister and husband in most of day. Pt calmer w/ family present.\nA/ P: delusional, paranoid, refusing all care\n ? psych and neuro consult\n CT on hold\n\n" }, { "category": "Nursing/other", "chartdate": "2196-10-01 00:00:00.000", "description": "Report", "row_id": 1363292, "text": "CCU Nursing Progress Note\nS: \"Can't you let me sleep?\"\nO:Please see flow sheet for full objective data\nCV: HR 51-65SB/NSR . BP 129-191/50-79 via NBP (good correlation with cuff pressure). SBP 191 was upon awakening pt, 10 minutes later, SBP 165. (Lisinopril due).\nResp: RR 17-21 o2 sat 95-97% with clear lungs.\nNeuro: difficult to assess orientation as patient at times refusing to answer questions. At times cooperative and following commands (turn on side, stick out tongue). At other times asking to be left alone, refusing medication. Receiving regularly scheduled dose zyprexa.\nSkin: right hip dressing D&I. Turned on side for sleep.\nEndo: hs fingerstick 115--> without insulin coverage.\nA: transient hypertension to SBP 190. Remains in sinus rhythm, no CP. BS in good range.\nP: continue to monitor HR/Rhythm/BP. For d/c in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-10-01 00:00:00.000", "description": "Report", "row_id": 1363293, "text": "Addendum to Nursing Progress Note\nBetween 0440 and 0530 had several short bursts of PAT, resolved spontaneously. See strip in chart.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-28 00:00:00.000", "description": "Report", "row_id": 1363287, "text": "CCU NPN 7a-7p\nS: \"How long will this pill take to kill me?\" \"Where is a member of my family?\"\nO: please see carevue for complete assessment data.\nNERUO: initially unarousable to sternal rub, more arousable as morning progressed, answering some questions and following some commands. When drawn into conversation increasingly agitated, refusing meds IV and PO and refusing most nursing care. 1.25mg disentegrating tab u/o effect, to ^ to 2.5mg . Refusing to be repositioned or OOB, new resting tremor ? r/t high doses of zyprexa yesterday.\n\nCV: BP up 200s/100s, restarted NTG gtt 2-3.5mcg/kg/min, started clonidine patch and cont NTG pacth. Refusing lisinopril, imdur d/c'd. Toprolol XL changed to 200mg (tolerated w/o incident). HR 70s-90s NSR w/ occasional PACs. No c/o CP. Distal pulses by doplar. K repletion (40meq/500cc) and mg 1.8 repleted w/ 2gm mg sulfate IV. Unable to draw PTT->pt. refused. Heparin off @ 1300 and to start lovenox (if able to administer).\n\nRESP: breathing comfortably on RA w/ SpO2 95-98%. LSCTA, diminished @ bases bilat. No c/o SOB. Weak non productive cough.\n\nGI/GU: abd soft, nontender, distended. +BS/-BM, minimal POs, refusing most offers of food/water. Voiding using bedpan and incontinent of small amts. UAC&S sent. ~350cc urine today.\n\nID: tmax 98.2 ax, to start ceftriaxone q12hrs IV but currently refusing IV meds. UAC&S pending.\n\nENDO: BG 154 @ noon, refusing insulin.\n\nSKIN: multiple areas of ecchymosis, DSD intact on R hip, incision not visualized. No breakdown noted. 2 PIVs patent and intact.\n\nSOC: spoke w/ sister on phone, expected to visit some time this afternoon, pt. requesting to see family and refusing further meds until they arrive.\n\nDISPO: CABG and PCI diferred indefinately, plan to medically manage BP and d/c to rehab/nursing home.\n\nA/P: restarted NTG gtt until able to cooperate and take POs. Cont to maintain SBP <140 if possible. Zypresa oral disintegrating tabs 2.5mg . Encourage activity, diet, and compliance w/ meds. OOB if possible. C/o to floor once BP stable.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-29 00:00:00.000", "description": "Report", "row_id": 1363288, "text": "CCU NPN 1900-0700\nO:\n\nconverting to Afib/flutter at 1900, rate 130, BP 130's/80. pt. with no CP/SOB. rx with total 10mg IV lopressor with better rate control and then back to NSR for short time. intermittantly going into AFib for short periods, rate 90-120's. BP dropping to 99-114/ and TNg gtt was weaned and then d/c'd ~ 2100. also given 250cc NS bolus given that pt. has low po intake, documented UTI. consistently staying in AF at 2330- rx with total 15mg IV dilt - converting to NSR for short time but then back into Afib- given another 15mg IV dilt at 0330 with good short term control, coverting to NSR and then back to Afib, rate 110-120's. BP stable 130-150's/.\n\ndiscussed with HO and will start Dilt gtt for persistant AFib.\nat 0600: pt. consistently in NSR rate 70's, stable BP. dilt. gtt not started at this time.\n\npt. denies SOB/CP\neve lytes: K+ 4.1/Mg 2.2----- Am pnd.\n\nResp: LS clear. RA sats 94-97%. breathing comf.\nGU: freq. incontinence in eve, every hour. foley replaced at 0200 for 1L u/o drained. since then u/o 50-60cc/hr. neg. 900cc since MN\n\nGI: no BM. refusing po's except for water\nneuro: pt. becoming more agitated at 1900- responding in anger, becoming more paranoid. given zyprexa 2.5mg disintegrating tablet with good effect. able to sleep but also wakes easily and is cooperative.\n\nskin: right hip surgical site dsg changed: staples approx. no drainange.. clean with areas of eccymosis. cleaned with NS and covered with DSD. skin tear in same area cleansed and covered with adaptic/DSD. coccyx has small area of redness: covered with duoderm.\n\n2 #20 PIV's\n\nA/P: back in AF/Flutter for long periods during night. dilt with good but short term effect.plan to start dilt gtt for persistant AF.\n- foley replaced d/t freq. incontinent- large amt. in bladder\n- good effect with zyprexa- slept well but still easily arousable\n- plan: OOB to chair today. follow lytes. monitor rythem and start dilt gtt if needed for AF. contin. all other CV meds as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-29 00:00:00.000", "description": "Report", "row_id": 1363289, "text": "ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\n\ns: now leave me alone....i'll be dead soon enough\no: id: afeb. cont on cipro for +ua.\ncv: raf this am w rates 120-140. rec'd iv dilt 10mg. alt b/w sr and raf most of day. rec'd additional 150mg iv bolus of amiodarone in am and po amio ^'d to 400mg qd and toprol ^'d to 300mg qd. pt did take both of these meds this am by 10am. sr in afternoon w rate 56-70, freq apcs. bp 130-160/70-80 via nbp. took lisinopril in afternoon, rec' ntg patch.\nno c/o cp. rec'd 2amps cagluc and 40meq kcl currently infusing.\nresp: no sob. sats >95% on ra. bs dim at bases.\ngi: poor intake, no stool.\ngu: foley to w good uop.\nskin: dsd to r hip. duoderm to coccyx. enc postion changes in bed w skin care.\nms: lethargic in am. more alert in afternoon. cooperative at times. freq stating\"i'm waiting to hear what's going to happen next\" reoriented freq though pt actually has good understanding of events. distrusts care. refusing to get oob today but may agree later particularly if family comes in. held am dose of zyprexa. took most of her cardiac meds but currenrtly refusing asa, synthroid which remain at bedside.\na: aflutter, htn. alt ms.\np: follow rhythm and hemodynamics. assess response to meds. safety precautions. enc po intake and ^activity as tol. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-30 00:00:00.000", "description": "Report", "row_id": 1363290, "text": "84 YR. OLD WOMAN WITH H/O HTN & MACULAR DEGENERATION.\n->FX R. HIP\n->REPAIR FX R. HIP @ OSH. POST-OP CP WITH GLOBAL ST CHANGES.\n TROPONIN (-).\n->TRANSFERRED TO CATH LAB->SEVERE 3VD INVOLVING L. MAIN.\n IABP INSERTED. SEEN BY CTSURG, WAS TO HAVE CABG ->CANCELLED\n D/T SPIKE T 102 & ARRHYTHMIA--AFIB/FLUTTER--R 130-180 REQUIRING\n IV LOPRESSOR & DILTIAZEM, & EVENTUALLY, DILT GTT.\nMOST RECENTLY, HAVING PERIODS OF CONFUSION, AGITATION, & HALLUCINA-\nTIONS->REFUSING NURSING CARE. TX WITH HALDOL/ZYPREXA.\n->FAMILY MEETING. DECISION MADE TO DECLINE CABG AT THIS POINT.\nMEDICAL MANAGEMENT. REHAB OPTIONS FOR HIP.\nSTILL HAVING EPISODES HTN & AFLUTTER AS RECENTLY AS , REQUIRING FURTHER MEDICATION ADJUSTMENTS->PT NOT ALWAYS COMPLIANT ABOUT TAKING MEDS.\n\nNEURO: A&O MOST OF NOC. PERIODS OF ANGER/AGITATION--WANTING EVERYONE OUT OF ROOM. WAS AWAKE MOST OF NOC.\n\nRESP: O2 SATS 96-98% ON RM. AIR. BS CLEAR BUT DIMINISHED AT BASES.\nRR 16-22.\n\nCARDIAC: HR 56-65 SB/SR, NO ECTOPY. BP 112-160/50-77. ~0215 C/O CP UNDER L. BREAST. VERY VAGUE, COULD NOT CHARACTERIZE PAIN OR RATE IT ON SCALE 1-10. EKG DONE->NO CHANGE. SL NTG X1.BP 170/66->158/64. HR 68->64 SR. NO FURTHER C/O CP.\n\nGI: ABD. SL. DISTENDED. NO STOOL. ??BM. APPETITE POOR.\n\nGU: FOLEY->CD PATENT & DRAINING YELLOW URINE WITH SEDIMENT. U/O 25-100\nCC/HR.\n\nID: AFEBRILE. CONT. ON IV LEVOFLOX FOR UTI.\n\nAM LABS PENDING.\n\nPLAN: REHAB PROCESS NEEDS TO BE INITIATED.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-30 00:00:00.000", "description": "Report", "row_id": 1363291, "text": "CCU NPN 7a-7p\nS: \"I'm willing to do whatever it takes to get to rehab, I know that I might need to go to a nursing home and that is fine with me.\"\nO: please see carevue, ICU update, for complete assessment data\nNEURO: A&Ox2-3, pleasant and cooperative with nursing care. Cont Zyprexa 2.5mg w/ adequate effect, cont w/ brief periods of paranoia and confusion but overall much improved. OOB->chair x 5 hours w/ heavy 2 assist. No c/o pain.\n\nCV: HD stable, lisinopril changed to 20mg ; tolerating all other cardiac meds w/ BP 130s-160s/80s-90s. HR NSR/SB 47-60s w/ no ectopy noted. Mg 1.8 repleted w/ 2gm MgSulfate IVPB. Trace/+1 edema RLE, distal pulses weak palp/dop. Remains CP free.\n\nRESP: breathing comfortably on RA w/ SpO2 > 95%. LSCTA, diminished @ bases bilaterally. Intermittent non-productive cough. Encouraged C/DB.\n\nGI/GU: abdomen soft, nontender, slightly distended. +BS/-BM, colase and senna (? has not had BM since admit). Ate well at breakfast, refusing lunch. Tol all PO meds. Foley draining CYU, -500cc since MN.\n\nID: low grade temp, tmax 99.1. Cipro changed to PO. WBC down.\n\nENDO: BG wnl, no SS humalog insulin coverage needed.\n\nSKIN: reddened area on coccyx left open to air, turned frequently and cushion while OOB->chair. Multiple areas of ecchymosis. R hip dsd intact, not visualized. 2 20G PIVs patent and intact.\n\nSOC: sisters in to visit briefly, updated by RN and case manager RE: POC d/c to rehab.\n\nDISPO: C/o to floor ( 6) if bed is needed, otherwise CCU onoc (to reduce emotional stress to pt.) and plan to d/c to Life Care Center of tomorrow. D/c planning completed in careweb and most paperwork printed.\n\nA/P: s/p r hip fx and repair complicated by new onset SSCP post-op, cath found severe 3vd, CABG and PCI deferred indefinately and plan to medically manage. Hospitalization c/b Af/flutter requiring dilt/lopressor/amio (last ), HTN->controled on multi-drug regimen, and dementia/ICU psychosis->responding to zyprexa. Continue present management and plan to d/c to rehab.\n" }, { "category": "ECG", "chartdate": "2196-10-01 00:00:00.000", "description": "Report", "row_id": 210363, "text": "Sinus bradycardia\nSupraventricular extrasystoles\nLong QTc interval\nrSr'(V1) - probable normal variant\nSince previous tracing, atrial premature complex new - clinical correlation is\nsuggested\n\n" }, { "category": "ECG", "chartdate": "2196-09-30 00:00:00.000", "description": "Report", "row_id": 210364, "text": "Sinus rhythm. Right ventricular conduction delay. Compared to the previous\ntracing of no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2196-09-30 00:00:00.000", "description": "Report", "row_id": 210365, "text": "Sinus rhythm. Right ventricular conduction delay. Compared to the previous\ntracing of atrial ectopy is no longer recorded. Otherwise, no\ndiagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2196-09-29 00:00:00.000", "description": "Report", "row_id": 210366, "text": "Sinus rhythm\nAtrial premature complex\nModest right ventricular conduction delay\nPossible left ventricular hypertrophy\nQ-Tc interval appears prolonged but is difficult to measure - clinical\ncorrelation is suggested\nSince previous tracing of , atrial fibrillation and lateral ST-T wave\nchanges now absent\n\n" }, { "category": "ECG", "chartdate": "2196-09-28 00:00:00.000", "description": "Report", "row_id": 210367, "text": "Atrial fibrillation with rapid ventricular response.\nModest right ventricular conduction delay\nPossible left ventricular hypertrophy\nLateral ST-T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , sinus rhythm now absent and lateral ST-T\nwave changes appears more prominent\n\n" }, { "category": "ECG", "chartdate": "2196-09-27 00:00:00.000", "description": "Report", "row_id": 210578, "text": "Normal sinus rhythm. Incomplete right bundle-branch block. Probable left\nventricular hypertrophy with secondary ST-T wave abnormalities. Compared to the\nprevious tracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2196-09-26 00:00:00.000", "description": "Report", "row_id": 210579, "text": "Sinus rhythm\nIncomplete right bundle branch block pattern\nProbable left ventricular hypertrophy\nDiffuse ST-T wave changes with Q-Tc interval appears prolonged but is difficult\nto measure - could be in part left ventricular hypertrophy, ischemia or\nmetabolic/drug effect - clinical correlation is suggested\nSince previous tracing of , ST-T wave changes less prominent\n\n\n" }, { "category": "ECG", "chartdate": "2196-09-25 00:00:00.000", "description": "Report", "row_id": 210580, "text": "Sinus rhythm\nIncomplete right bundle branch block pattern\nProbable left ventricular hypertrophy\nDiffuse ST-T wave changes with Q-Tc interval appears prolonged but is difficult\nto measure - could be in part left ventricular hypertrophy, ischemia or\nmetabolic/drug effect - clinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2196-09-25 00:00:00.000", "description": "Report", "row_id": 210581, "text": "Sinus rhythm. Prolonged QTc interval. Incomplete right bundle-branch block\npattern. Early R waves - consider right ventricular hypertrophy. Possible left\nventricular hypertrophy. Compared to the previous tracing of no change.\n\n\n" }, { "category": "ECG", "chartdate": "2196-09-23 00:00:00.000", "description": "Report", "row_id": 210582, "text": "Sinus rhythm. Incomplete right bundle-branch block. Left ventricular\nhypertrophy. Diffuse non-specific ST-T wave changes. Compared to the previous\ntracing no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2196-09-22 00:00:00.000", "description": "Report", "row_id": 210583, "text": "Atrial flutter. Incomplete right bundle-branch block. Left ventricular\nhypertrophy. Diffuse non-specific ST-T wave changes. Compared to the previous\ntracing no significant changes.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2196-09-23 00:00:00.000", "description": "Report", "row_id": 210584, "text": "Sinus rhythm. Atrial ectopy. Left ventricular hypertrophy. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing sinus rhythm is now\npresent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2196-09-21 00:00:00.000", "description": "Report", "row_id": 210585, "text": "Coarse atrial fibrillation versus flutter with variable block. No change\nST-T wave abnormalities. Compared to tracing of atrial\nfibrillation/flutter is new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2196-09-20 00:00:00.000", "description": "Report", "row_id": 210586, "text": "Atrial fibrillation with a rapid ventricular response. RSR' pattern in\nleads V1-V2 consistent with right ventricular conduction delay. ST segment\ndepressions in leads I, aVL and V3-V6 suggest possible anterolateral ischemia\nwhich may represent rate-related changes. Compared to the previous tracing\nof the ST segment depressions and atrial fibrillation are new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2196-09-20 00:00:00.000", "description": "Report", "row_id": 210587, "text": "Sinus rhythm\nAtrial premature complexes\nRight ventricular conduction delay/incomplete right bundle branch block pattern\nConsider left ventricular hypertrophy by voltage\nNo previous tracing for comparison\n\n" }, { "category": "Radiology", "chartdate": "2196-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882086, "text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? CHF\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with 3vd here for cabg\n\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE\n\n INDICATION: 84-year-old woman with is pre-operation for CABG, CHF.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of . The radiograph is\n markedly suboptimal with rotation.\n\n The lungs are clear. The heart and mediastinum within normal limits. There\n is no evidence of congestive heart failure. No pneumothorax is identified.\n There is continued tortuosity of the thoracic aorta.\n\n IMPRESSION: No active lung disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-09-26 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 882834, "text": " 6:09 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: FALLING HCT SP CATH RT HIP FX LARGE HEMATOMA R/O BLEED\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p R hip fx 3 weeks ago with 3 vessel CAD s/p cath, now with\n falling hct, r/o large hematoma at surgical site or RP bleed.\n REASON FOR THIS EXAMINATION:\n r/o R hip hematoma or RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman S/P right hip fracture 3 weeks ago with falling\n hematocrit. Evaluate for hematoma or retroperitoneal hemorrhage.\n\n TECHNIQUE: Contiguous axial CT images of the pelvis were obtained without\n oral or IV contrast.\n\n FINDINGS: Evaluation of the pelvis is limited due to extensive streak\n artifact from the prosthetic hip on the right side. Within the limitations of\n study no obvious hematoma or retroperitoneal hemorrhage is visualized. The\n pelvic loops of small and large bowel appear grossly unremarkable. There is\n extensive calcifications of the aorta and its pelvic branches. A calcified\n area is visualized in the pelvis, likely representing calcified lymph nodes. A\n right- sided pelvic kidney is noted.\n\n There are no effusions or pelvic or inguinal lymphadenopathy.\n\n No suspicious lytic or blastic lesions in the osseous structures identified.\n Prosthetic right hip is noted.\n\n IMPRESSION: Limited study due to extensive streak artifact from the\n prosthetic right hip. Within the limitations of study there is no evidence of\n hemorrhage or retroperitoneal bleed.\n\n" }, { "category": "Radiology", "chartdate": "2196-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882409, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF eval\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with 3vd here for cabg\n\n REASON FOR THIS EXAMINATION:\n CHF eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old with CABG for evaluation of CHF.\n\n FINDINGS: There is mild cardiomegaly. The aorta is tortuous. There is a\n small left-sided effusion. The lung fields are otherwise clear.\n\n IMPRESSION: Mild cardiomegaly. There is small left pleural effusion. No\n CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-09-20 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 882012, "text": " 1:58 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: PREOP CABG\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with severe Left main and 3vd going for CABG\n REASON FOR THIS EXAMINATION:\n please assess carotids\n ______________________________________________________________________________\n FINAL REPORT\n REASON: Left main disease undergoing CABG.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. This is\n somewhat difficult to interpret study due to the counterpulsations in the\n intraaortic balloon pump. Moderate plaque was identified on the left.\n\n On the right, peak systolic velocities are 113, 150, 226 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.7. This is consistent with less than\n 40% stenosis.\n\n On the left, peak systolic velocities are 133, 166, 200 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.8. This is consistent with a 40% to\n 59% stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Moderate left-sided plaque with 40% to 59% carotid stenosis. On\n the right is less than 40% stenosis. Of note, it is somewhat difficult to\n interpret study due to the intraaortic balloon pump counterpulsations.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881940, "text": " 7:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate fluid status\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with 3vd here for cabg\n REASON FOR THIS EXAMINATION:\n evaluate fluid status\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW\n\n INDICATION: 3-vessel disease, here for bypass surgery, evaluate fluid status.\n\n FINDINGS: AP view of the patient in semi-upright position has been obtained.\n Two films were exposed in succession. The heart size remains within normal\n limits, paying attention to portable technique. The configuration suggests\n prominence of the left ventricular contour which in conjunction with the\n mildly widened and elongated thoracic aorta is compatible with systemic\n hypertension. Small linear calcium deposits are noted in the wall of the\n thoracic aorta at the level of the arch. No local aortic contour\n abnormalities identified. The pulmonary vasculature is within normal limits\n and thus there is no evidence of vascular distention, interstitial or alveolar\n edema. Also, the lateral pleural sinuses are free. Skeletal structures\n demonstrate moderate degree of diffuse demineralization but no local skeletal\n abnormalities are identified in the thoracic area. On the second film\n exposure, one observes a longitudinal translucency in the thoracic aorta,\n indicative of the placement of an intraaortic balloon. A metallic marker at\n the top is in location just below the arch portion of the thoracic aorta and\n thus at an appropriate level the placement of an intraaortic balloon device is\n confirmed.\n\n There is exists no prior chest examination available for comparison.\n\n IMPRESSION: No evidence of vascular fluid overload, pulmonary vascular venous\n congestion or pleural effusion.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2123-12-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1050993, "text": " 8:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ro stroke\n Admitting Diagnosis: CEREBRAL ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with\n REASON FOR THIS EXAMINATION:\n ro stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe SAT 10:29 PM\n No interval change from one day prior. Stable small likely postoperative\n right extra-axial hematoma. Slight interval increase in air-fluid level\n within the right sphenoid sinus which is likely related to intubated status.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for stroke in patient status post right MCA aneurysm\n clipping.\n\n Comparison is made to examination dated .\n\n NON-CONTRAST HEAD CT\n\n Streak artifact from prior coiling/clipping of right MCA aneurysm as well as\n in the region of basilar tip are unchanged, as is small right extra-axial\n hematoma, which is likely postoperative in nature. Chronic small vessel\n ischemic changes within the periventricular white matter and left corona\n radiata are stable with remaining -white matter differentiation appearing\n preserved. No new fluid collections, significant mass effect or midline shift\n is identified. Air-fluid level within the right sphenoid sinus has increased\n with remaining paranasal sinuses appearing well aerated. Postoperative\n changes from prior right craniotomy with adjacent subcutaneous emphysema and\n surgical staples is not significantly changed.\n\n IMPRESSION:\n 1. No significant interval change from one day prior with stable small right\n extra-axial, likely postoperative hematoma. No CT findings to suggest acute\n stroke.\n\n 2. Slight interval increase in air-fluid level within the right sphenoid\n sinus, likely related to intubated status, although acute sinusitis is not\n excluded.\n\n" }, { "category": "Radiology", "chartdate": "2123-12-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1050994, "text": ", J. NSURG SICU-A 8:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ro stroke\n Admitting Diagnosis: CEREBRAL ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with\n REASON FOR THIS EXAMINATION:\n ro stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No interval change from one day prior. Stable small likely postoperative\n right extra-axial hematoma. Slight interval increase in air-fluid level\n within the right sphenoid sinus which is likely related to intubated status.\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 1050809, "text": " 3:14 PM\n CAROT/CEREB Clip # \n Reason: s/p crani for aneurysm clipping(basilar)\n Admitting Diagnosis: CEREBRAL ANEURYSM/SDA\n Contrast: OPTIRAY Amt: 100\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post clipping of the right middle cerebral artery\n aneurysms. The patient is here for post clipping angiogram.\n\n TECHNIQUE: Informed consent was obtained from the patient and the patient's\n family after explaining the risks, indications and alternative management.\n Risks explained included stroke, loss of vision and speech, temporary or\n permanent, with possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall , under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the , a 0.35 wire was introduced and the taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\n and connected to continuous saline infusion (with mixture of 1000 units of\n heparin in 1000 cc of saline).\n\n The following vessels were selectively catheterized and arteriograms were\n performed from these locations:\n\n 1. Right internal carotid artery.\n 2. Left common carotid artery.\n 3. Left vertebral artery.\n\n Evaluation of these vessels demonstrate successful clipping of the known right\n middle cerebral artery aneurysm.\n\n The previously noted basilar artery aneurysm is also well coiled.\n\n IMPRESSION:\n\n Successful clipping of the right middle cerebral artery aneurysms. No\n definite residual aneurysm noted. Minimal paucity is noted in the region of\n the branches of the right middle cerebral artery. No major vessel occlusion\n noted.\n (Over)\n\n 3:14 PM\n CAROT/CEREB Clip # \n Reason: s/p crani for aneurysm clipping(basilar)\n Admitting Diagnosis: CEREBRAL ANEURYSM/SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050849, "text": " 6:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop. ETT placement\n Admitting Diagnosis: CEREBRAL ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p crani and aneurysm clipping\n REASON FOR THIS EXAMINATION:\n postop. ETT placement\n ______________________________________________________________________________\n WET READ: ARHb FRI 7:49 PM\n ETT 2.9 cm above carina. Patient rotation limits evaluation of left base and\n opacity or effusion are difficult to exclude.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Craniotomy and aneurysm clipping.\n\n Comparison is made to the prior study from .\n\n FINDINGS:\n\n Endotracheal tube terminates at the thoracic inlet, approximately 3 cm above\n the carina. There is continued left lower lobe atelectasis and a small left\n pleural effusion. Right lung is clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1050858, "text": " 8:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: postop changes. ***PLEASE SCAN ON , 2100***\n Admitting Diagnosis: CEREBRAL ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p right crani and aneurysm clipping\n REASON FOR THIS EXAMINATION:\n postop changes. ***PLEASE SCAN ON , 2100***\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old female status post right craniotomy and aneurysm\n clipping.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: Postsurgical changes related to a right frontal\n craniotomy, basilar tip aneurysm coiling, and a right MCA aneurysm clipping is\n identified. Note is made of a new high attenuation right frontal extra-axial\n collection measuring 5 mm. There is no significant shift of normally midline\n structures or evidence of major vascular territorial infarct. The -white\n matter differentiation is preserved. Small focus of hypoattenuation in the\n left frontal lobe (2:17) is unchanged. Note is made of a small air-fluid level\n in the sphenoid sinus. The remainder of the visualized paranasal sinuses and\n mastoid air cells are normally aerated.\n\n IMPRESSION: Post-operative changes as described. New right frontal high\n attenuation extra- axial collection likely post-operative in nature.\n Follow up recommended. Discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "ANGIO, CAROTID.CEREBRAL UNILAT", "row_id": 1050768, "text": " 1:14 PM\n OR VASCULAR A-GRAM Clip # \n Reason: (R)CRANI FOR ANEURYSM CLIPPING. **OR CASE**Anesthesia has be\n ********************************* CPT Codes ********************************\n * ANGIO, CAROTID.CEREBRAL UNILAT -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with aneurysm\n REASON FOR THIS EXAMINATION:\n (R)CRANI FOR ANEURYSM CLIPPING. **OR CASE**Anesthesia has been book for \n at 9am.\n ______________________________________________________________________________\n FINAL REPORT\n Please see CareWeb Notes for the complete operative report.\n\n" }, { "category": "Nursing", "chartdate": "2123-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649444, "text": "TITLE:\n Aneurysm, other\n Assessment:\n neuro exam unchanged\n ambulating in room with one assist\n tol reg diet\n foley dc\nd by day shift was dtv\n pt requiring frequent medication with pain meds\n Action:\n pt voiding in commode\n neuro checks q4h\n dilaudid iv prn\n Response:\n neuro exam unchanged\n pain states pain is being adequately controlled\n Plan:\n awaiting floor bed\n" }, { "category": "Rehab Services", "chartdate": "2123-12-06 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 649499, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: aneurysm /\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 51F recent admit\n w/ HA, SAH s/p coiling of basal tip aneurysm, L frontal\n ventriculostomy on , then found to have vasospasm of ant & post\n circ s/p IA verapamil & on HHH therapy, meningitis. Presented\n for elective R Craniotmoy for R MCA Aneurysm Clipping x2. Of\n note, sig clamp time of R MCA.\n Past Medical / Surgical History: HTN, ischemic colitis, SAH as above\n Medications: Dilaudid, Lisinopril, HydrALAzine,\n Radiology: Head CT: stable small right extra-axial, likely\n postoperative hematoma\n Labs:\n 31.3\n 10.8\n 364\n 7.0\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: Will be staying with sister upon d/c,\n prior to admit in pt worked in rehab hospital working as a nursing\n aid.\n Living Environment: Pts sister\ns house has 3STE, one level once inside\n Prior Functional Status / Activity Level: PTA pt was I with ambulation\n and ADLs, had been getting home OT/PT services\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O x 3, able to\n recall 3 out of 3 items after 5 mins with cuing for one item. Pt\n follows all 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 68\n 129/64\n 97 % 3L\n Rest\n /\n Sit\n 78\n 129/71\n 93% RA\n Activity\n /\n Stand\n /\n Recovery\n 79\n 136/78\n 97% 2L\n Total distance walked:\n Minutes:\n Pulmonary Status: Diminished LS t/o, strong nonproductive cough\n Integumentary / Vascular: Craniotomy site open to air, with no signs of\n drainage, R orbital edema\n Sensory Integrity: Intact to LT t/o\n Pain / Limiting Symptoms: Pt reports mild HA t/o evaluation\n Posture: unremarkable\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n L shldr flexion 3+/5\n L elb flexion \n L knee extension 3+/5\n L hip flexion 3+/5\n Motor Function: No abnormal movement patterns, visual fields intact,\n with slightly slowed velocity but coordinated. symmetrical smile.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was able to take 5 steps bed to chair with CG\n Decreased step length B'ly\n No marked deviations from limited assessment\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\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\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Good static and dynamic sitting balance. Pt was able to stand\n and perform standing marching with CG and no LOB\n Education / Communication: Pt status discussed with RN, pt educated on\n role of PT\n Intervention:\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Gait, Impaired\n Clinical impression / Prognosis: 51 yo f s/p R craniotomy for MCA\n aneurysm presents with above impairments c/w nonprogressive CNS\n dysfunction. Pt is currently functioning below baseline, however based\n on current functional status and PLOF feel she will progress to safe\n level of I for d/c home with family support.\n Goals\n Time frame: 1wk\n 1.\n I transfers\n 2.\n I amb > 300'\n 3.\n I increase decrease 3 stairs\n 4.\n Increase MMT t/o\n 5.\n 6.\n Anticipated Discharge: Home\n Treatment Plan:\n Frequency / Duration: 2-3x.wk\n Progress ambulation and activity, cont pt education and d/c planning.\n Pt should be OOB > 3x/day c A\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2123-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649242, "text": "Aneurysm, other\n Assessment:\n - pt alert and oriented X3\n - Weak on Left side upper and lower extremities\n - DP and DT pulses present bilaterally\n Action:\n - Neuro checks changed to q4h\n - advanced diet to regular as tolerated\n Response:\n - neuro status unchanged throughout shift\n - strength on left side improving throughout the day, now only\n slightly weaker than Right\n - tolerated diet well, feeds self\n - complains of some jaw pain when having to chew food\n Plan:\n - ordered soft foods for dinner\n - continue to assess neuro status and strength of extremities\n Pain control (acute pain, chronic pain)\n Assessment:\n - Pt complains of headache throughout shift\n Action:\n - dilaudid 2-4mg PO q4h PRN\n - Dilaudid 0.5-2mg IV q3h PRN\n Response:\n - Pt reports short term pain relief from 4mg dilaudid PO q4h\n - also requires -.5-1mg dilaudid IV between doses\n Plan:\n - continue to assess for and treat pain\n - continue frequent turning/repositioning\n" }, { "category": "Physician ", "chartdate": "2123-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 649315, "text": "TITLE:\n SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n Chief complaint:\n headache\n PMHx:\n Current medications:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n : Keppra 1500mg\", Lisinopril 10mg',Vicodin prn\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:49 PM\n INVASIVE VENTILATION - STOP 08:18 PM\n rpt ct scan unchanged, tx'd 2 units PRBC, residual L arm weakness.\n Post operative day:\n POD#2 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.3\nC (99.1\n HR: 86 (64 - 101) bpm\n BP: 112/62(74) {84/49(60) - 112/85(88)} mmHg\n RR: 19 (11 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,806 mL\n 33 mL\n PO:\n 700 mL\n Tube feeding:\n IV Fluid:\n 1,381 mL\n 33 mL\n Blood products:\n 725 mL\n Total out:\n 1,875 mL\n 820 mL\n Urine:\n 1,740 mL\n 820 mL\n NG:\n Stool:\n Drains:\n 135 mL\n Balance:\n 931 mL\n -787 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Murmur: No(t) Systolic, No(t) Diastolic)\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 Labs / Radiology\n 333 K/uL\n 10.6 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 106 mEq/L\n 139 mEq/L\n 30.3 %\n 7.8 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n 02:53 PM\n 02:01 AM\n WBC\n 9.3\n 10.5\n 10.1\n 7.8\n Hct\n 32.9\n 32.7\n 30.5\n 27.1\n 30.3\n Plt\n 444\n 507\n 438\n 333\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.6\n TCO2\n 24\n 23\n 26\n Glucose\n 146\n 136\n 133\n 99\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:8.7 mg/dL, Mg:1.6 mg/dL, PO4:3.1 mg/dL\n Imaging: : CT Head: Post-operative changes as described. New right\n frontal high attenuation extra- axial collection likely post-operative\n in nature.\n CT: head: no significant change, slight incr air fluid lvl in r\n sphenoid sinus\n Assessment and Plan\n ANEMIA, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), ANEURYSM, OTHER\n Assessment and Plan: 51F s/p craniectomy/clipping of MCA aneurysm\n Neurologic: s/p elective clipping R MCA aneurysm; Q2hr check, head CT\n postop unchanged. continues to have some L arm weakness. keppra PO,\n dilaudid prn.\n Cardiovascular: goal SBP <160, nicardipine gtt off, lisinopril PO,\n hydral PRN\n Pulmonary: s/p extubation, no issues\n Gastrointestinal / Abdomen: Regular diet, tolerating\n Nutrition: Regular diet\n Renal: UOP ok, heplocked\n Hematology: Crit trending down, 30.7 from 27 after 2 units\n Endocrine: RISS, fingersticks OK\n Infectious Disease: No Abx, afebrile, WBC normal\n Lines / Tubes / Drains: PIV, foley\n Wounds: C/D/I, JP DC'd\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:22 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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2123-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649310, "text": "TITLE:\n Anemia, other\n Assessment:\n Hct 27.1\n Action:\n Two units prbc transfused\n Response:\n Hct 30.3\n Plan:\n Monitor hct\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o headache\n Action:\n Dilaudid 4mg po q4h\n Dilaudid 1mg iv prn\n Response:\n Pt states pain level is tolerable on current pain medication regimen\n Plan:\n Continue with current pain management\n Aneurysm, other\n Assessment:\n Neuro checks q2h\n Pt alert and oriented x 3\n Only neuro deficit is slight weakness of left upper and lower\n extremities\n Action:\n Neuro checks q2h\n Ct scan done as ordered\n Response:\n Neuro exam remains unchanged\n Plan:\n Neuro checks q2h\n Transfer to floor when bed available\n" }, { "category": "Respiratory ", "chartdate": "2123-12-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 649078, "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: 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: /\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: Maintain PEEP at current level and reduce FiO2 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 Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2123-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649275, "text": "HPI: 51F who initially presented w/ HA -> SAH s/p coiling of\n basal tip aneurysm, L frontal ventriculostomy on , then found to\n have vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis.\n Presents for elective Rt Crani for R MCA Aneurysm Clipping\n x2. Of note, sig clamp time of R MCA.\n PMH: Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n To SICU for postop monitoring\n Transfer to floor\n Aneurysm, other\n Assessment:\n - pt alert and oriented X3\n - Weak on Left side upper and lower extremities\n - DP and DT pulses present bilaterally\n Action:\n - Neuro checks changed to q4h\n - advanced diet to regular as tolerated\n Response:\n - neuro status unchanged throughout shift\n - strength on left side improving throughout the day, now only\n slightly weaker than Right\n - tolerated diet well, feeds self\n - complains of some jaw pain when having to chew food\n Plan:\n - ordered soft foods for dinner\n - continue to assess neuro status and strength of extremities\n Pain control (acute pain, chronic pain)\n Assessment:\n - Pt complains of headache throughout shift\n Action:\n - dilaudid 2-4mg PO q4h PRN\n - Dilaudid 0.5-2mg IV q3h PRN\n Response:\n - Pt reports short term pain relief from 4mg dilaudid PO q4h\n - also requires -.5-1mg dilaudid IV between doses\n Plan:\n - continue to assess for and treat pain\n - continue frequent turning/repositioning\n Anemia, other\n Assessment:\n - pt hematorcit decreased from 30.5 to 27.1\n Action:\n - giving pt 2 units PRBC over 3 hours and checking HCT one\n hour after completion\n Response:\n - awaiting response\n Plan:\n - monitor pt while receiving blood products\n - continue to closely monitor Hematocrit level\n" }, { "category": "Respiratory ", "chartdate": "2123-12-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 649127, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 22 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 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 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: extubate\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: needed to go to CT\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n CT\n 2100\n Comments:\n" }, { "category": "Physician ", "chartdate": "2123-12-04 00:00:00.000", "description": "Intensivist Note", "row_id": 649175, "text": "SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n Chief complaint:\n elective Rt Crani for R MCA Aneurysm Clipping x2\n PMHx:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - START 05:21 PM\n INVASIVE VENTILATION - START 05:25 PM\n NASAL SWAB - At 05:27 PM\n OR RECEIVED - At 05:54 PM\n MULTI LUMEN - START 06:18 PM\n pt arrived to sicu with a single lumen central line in her right groin\n MULTI LUMEN - STOP 01:40 AM\n pt arrived to sicu with a single lumen central line in her right groin\n EXTUBATION - At 02:30 AM\n Post operative day:\n POD#1 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:20 AM\n Other medications:\n Flowsheet Data as of 05:21 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: 36.6\nC (97.9\n HR: 68 (68 - 121) bpm\n BP: 100/55(73) {85/51(62) - 209/128(161)} mmHg\n RR: 11 (0 - 25) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,020 mL\n 423 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,020 mL\n 423 mL\n Blood products:\n Total out:\n 9,345 mL\n 380 mL\n Urine:\n 1,480 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 165 mL\n 60 mL\n Balance:\n -1,325 mL\n 43 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): 486 (450 - 486) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 94%\n ABG: 7.36/45/194/25/0\n Ve: 7 L/min\n PaO2 / FiO2: 388\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 : slightly b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\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), (Responds to: Verbal\n stimuli), No(t) Moves all extremities, (LUE: Weakness), weak LUE, moves\n all other extremities\n Labs / Radiology\n 438 K/uL\n 10.1 g/dL\n 133 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 30.5 %\n 10.1 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n WBC\n 9.3\n 10.5\n 10.1\n Hct\n 32.9\n 32.7\n 30.5\n Plt\n 444\n 507\n 438\n Creatinine\n 0.5\n 0.6\n 0.6\n TCO2\n 24\n 23\n 26\n Glucose\n 146\n 136\n 133\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Assessment and Plan: 51yo F s/p elective Rt Crani for R MCA Aneurysm\n Clipping x2\n Neurologic: s/p elective clipping R MCA aneurysm; Q1hr check, head CT\n postop done. keppra PO, dilaudid prn, plan for CT head in PM to\n r/o stroke --d/w neurosurg when want to do scan\n Cardiovascular: goal SBP <160, nicardipine gtt off, lisinopril PO\n Pulmonary: s/p extubation, nasal cannula as needed\n Gastrointestinal / Abdomen: no issues.\n Nutrition: sips and advance to regular diet\n Renal: Foley, Adequate UO\n Hematology: routine postop labs, follow jp output\n Endocrine: RISS\n Infectious Disease: vanc x2doses postop\n Lines / Tubes / Drains: Foley, left femoral A-line (unable to get\n radial/brachial a-line preop)\n Wounds: right groin w/o hematoma\n Imaging: CT scan head today\n Fluids: KVO once taking adequate PO\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition: advance\n Glycemic Control:\n Lines:\n Arterial Line - 05:21 PM\n 16 Gauge - 05:22 PM\n 18 Gauge - 05:22 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2123-12-04 00:00:00.000", "description": "Intensivist Note", "row_id": 649179, "text": "SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n Chief complaint:\n elective Rt Crani for R MCA Aneurysm Clipping x2\n PMHx:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - START 05:21 PM\n INVASIVE VENTILATION - START 05:25 PM\n NASAL SWAB - At 05:27 PM\n OR RECEIVED - At 05:54 PM\n MULTI LUMEN - START 06:18 PM\n pt arrived to sicu with a single lumen central line in her right groin\n MULTI LUMEN - STOP 01:40 AM\n pt arrived to sicu with a single lumen central line in her right groin\n EXTUBATION - At 02:30 AM\n Post operative day:\n POD#1 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:20 AM\n Other medications:\n Flowsheet Data as of 05:21 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: 36.6\nC (97.9\n HR: 68 (68 - 121) bpm\n BP: 100/55(73) {85/51(62) - 209/128(161)} mmHg\n RR: 11 (0 - 25) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,020 mL\n 423 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,020 mL\n 423 mL\n Blood products:\n Total out:\n 9,345 mL\n 380 mL\n Urine:\n 1,480 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 165 mL\n 60 mL\n Balance:\n -1,325 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n extubated early Am\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 486 (450 - 486) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 94%\n ABG: 7.36/45/194/25/0\n Ve: 7 L/min\n PaO2 / FiO2: 388\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 : slightly b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\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), (Responds to: Verbal\n stimuli), No(t) Moves all extremities, (LUE: Weakness), weak LUE, moves\n all other extremities\n Labs / Radiology\n 438 K/uL\n 10.1 g/dL\n 133 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 30.5 %\n 10.1 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n WBC\n 9.3\n 10.5\n 10.1\n Hct\n 32.9\n 32.7\n 30.5\n Plt\n 444\n 507\n 438\n Creatinine\n 0.5\n 0.6\n 0.6\n TCO2\n 24\n 23\n 26\n Glucose\n 146\n 136\n 133\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Assessment and Plan: 51yo F s/p elective Rt Crani for R MCA Aneurysm\n Clipping x2\n Neurologic: s/p elective clipping R MCA aneurysm; Q1hr check, head CT\n postop done. keppra PO, dilaudid prn, plan for CT head in PM to\n r/o stroke --d/w neurosurg when want to do scan\n Cardiovascular: goal SBP <160, nicardipine gtt off, lisinopril PO\n Pulmonary: s/p extubation, nasal cannula as needed\n Gastrointestinal / Abdomen: no issues.\n Nutrition: sips and advance to regular diet\n Renal: Foley, Adequate UO\n Hematology: routine postop labs, follow jp output\n Endocrine: RISS\n Infectious Disease: vanc x2doses postop\n Lines / Tubes / Drains: Foley, left femoral A-line (unable to get\n radial/brachial a-line preop)\n Wounds: right groin w/o hematoma\n Imaging: CT scan head today\n Fluids: KVO once taking adequate PO\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition: advance\n Glycemic Control:\n Lines:\n Arterial Line - 05:21 PM\n 16 Gauge - 05:22 PM\n 18 Gauge - 05:22 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2123-12-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 649180, "text": "Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n CT\n 2100\n Comments: Pt extubated without incident. Placed on aerosol.\n" }, { "category": "Nursing", "chartdate": "2123-12-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 649435, "text": "HPI: 51F who initially presented w/ HA -> SAH s/p coiling of\n basal tip aneurysm, L frontal ventriculostomy on , then found to\n have vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis.\n Presents for elective Rt Crani for R MCA Aneurysm Clipping\n x2. Of note, sig clamp time of R MCA.\n PMH: Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n To SICU for postop monitoring\n Transfer to floor ?\n Aneurysm, other\n Assessment:\n - pt alert and oriented X3\n - Slightly weaker on Left side upper and lower extremities\n - Complaint of nausea\n Action:\n - Neuro checks changed to q4h\n - advanced diet to regular as tolerated\n - OOB to chair\n - Given zofran 2mg\n Response:\n - neuro status unchanged throughout shift\n - tolerates diet well, feeds self\n - complains of some jaw pain when having to chew food\n - steady on feet, requires supervision while transferring OOB\n - good response from zofran, currently denies nausea\n Plan:\n - order soft foods for meals\n - continue to get OOB\n - continue to assess neuro status and strength of extremities\n Pain control (acute pain, chronic pain)\n Assessment:\n - Pt complains of headache throughout shift\n Action:\n - Pain control regimen changed to dilaudid IV 0.5-2.5mg IV q2h\n Response:\n - Pt reports better pain control\n Plan:\n - continue to assess for and treat pain\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CEREBRAL ANEURYSM/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 67 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Precautions: Contact\n PMH:\n CV-PMH: Hypertension\n Additional history: ischemic colitis, coiling of basilar tip aneurysm,\n heartburn, elevated platelet count, sah with hydrocephalus, vent drain,\n vasospasm, headaches, mrsa\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:67\n Temperature:\n 98.8\n Arterial BP:\n S:121\n D:75\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 50 mL\n 24h total out:\n 1,490 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 02:01 AM\n Potassium:\n 3.7 mEq/L\n 02:01 AM\n Chloride:\n 106 mEq/L\n 02:01 AM\n CO2:\n 27 mEq/L\n 02:01 AM\n BUN:\n 10 mg/dL\n 02:01 AM\n Creatinine:\n 0.6 mg/dL\n 02:01 AM\n Glucose:\n 99 mg/dL\n 02:01 AM\n Hematocrit:\n 30.3 %\n 02:01 AM\n Finger Stick Glucose:\n 151\n 09:00 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: \n Transferred to:\n Date & time of Transfer:\n" }, { "category": "General", "chartdate": "2123-12-03 00:00:00.000", "description": "Generic Note", "row_id": 649115, "text": "TITLE:\n SICU NURSING ADMIT NOTE:\n Received pt at 1730 s/p OR for aneurysm clipping and then angio. Pt\n intubated on propofol. Nicardipine started to control bp, goal sbp\n <140. sheath pulled by IR fellow at bedside without incident. Md\n notified of mag 1.4, being repleted now. Md notified of lactic acid\n 4.1, level to be repeated. Pt unreversed from OR, unable to complete\n neuro exam until paralytics wear off. Pupils equal and reactive. One\n fluid bolus given 500cc per dr. . Report given to night rn.\n" }, { "category": "Physician ", "chartdate": "2123-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 649335, "text": "TITLE:\n SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n Chief complaint:\n headache\n PMHx:\n Current medications:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n : Keppra 1500mg\", Lisinopril 10mg',Vicodin prn\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:49 PM\n INVASIVE VENTILATION - STOP 08:18 PM\n rpt ct scan unchanged, tx'd 2 units PRBC, residual L arm weakness.\n Post operative day:\n POD#2 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.3\nC (99.1\n HR: 86 (64 - 101) bpm\n BP: 112/62(74) {84/49(60) - 112/85(88)} mmHg\n RR: 19 (11 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,806 mL\n 33 mL\n PO:\n 700 mL\n Tube feeding:\n IV Fluid:\n 1,381 mL\n 33 mL\n Blood products:\n 725 mL\n Total out:\n 1,875 mL\n 820 mL\n Urine:\n 1,740 mL\n 820 mL\n NG:\n Stool:\n Drains:\n 135 mL\n Balance:\n 931 mL\n -787 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Murmur: No(t) Systolic, No(t) Diastolic)\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 Labs / Radiology\n 333 K/uL\n 10.6 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 106 mEq/L\n 139 mEq/L\n 30.3 %\n 7.8 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n 02:53 PM\n 02:01 AM\n WBC\n 9.3\n 10.5\n 10.1\n 7.8\n Hct\n 32.9\n 32.7\n 30.5\n 27.1\n 30.3\n Plt\n 444\n 507\n 438\n 333\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.6\n TCO2\n 24\n 23\n 26\n Glucose\n 146\n 136\n 133\n 99\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:8.7 mg/dL, Mg:1.6 mg/dL, PO4:3.1 mg/dL\n Imaging: : CT Head: Post-operative changes as described. New right\n frontal high attenuation extra- axial collection likely post-operative\n in nature.\n CT: head: no significant change, slight incr air fluid lvl in r\n sphenoid sinus\n Assessment and Plan\n ANEMIA, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), ANEURYSM, OTHER\n Assessment and Plan: 51F s/p craniectomy/clipping of MCA aneurysm\n Neurologic: s/p elective clipping R MCA aneurysm; Q2hr check, head CT\n postop unchanged. continues to have some L arm weakness. keppra PO,\n increase dilaudid prn for uncontrolled pain so far\n Cardiovascular: goal SBP <160, lisinopril PO, hydral PRN\n Pulmonary: s/p extubation, no issues\n Gastrointestinal / Abdomen: Regular diet, tolerating\n Nutrition: Regular diet\n Renal: UOP ok, heplocked\n Hematology: Crit trending down, 30.7 from 27 recieved 2 units\n Endocrine: RISS, fingersticks OK\n Infectious Disease: No Abx, afebrile, WBC normal\n Lines / Tubes / Drains: PIV, foley\n Wounds: C/D/I, JP DC'd\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines: d/c foley\n 18 Gauge - 05:22 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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 12 minutes\n" }, { "category": "Nursing", "chartdate": "2123-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649338, "text": "TITLE:\n Anemia, other\n Assessment:\n Hct 27.1\n Action:\n Two units prbc transfused\n Response:\n Hct 30.3\n Plan:\n Monitor hct\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o headache\n Action:\n Dilaudid 4mg po q4h\n Dilaudid 1mg iv prn\n Response:\n Pt states pain level is tolerable on current pain medication regimen\n Plan:\n Continue with current pain management\n Aneurysm, other\n Assessment:\n Neuro checks q2h\n Pt alert and oriented x 3\n Only neuro deficit is slight weakness of left upper and lower\n extremities\n Action:\n Neuro checks q2h\n Ct scan done as ordered\n Response:\n Neuro exam remains unchanged\n Plan:\n Neuro checks q2h\n Transfer to floor when bed available\n" }, { "category": "Physician ", "chartdate": "2123-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 649339, "text": "TITLE:\n SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n Chief complaint:\n headache\n PMHx:\n Current medications:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n : Keppra 1500mg\", Lisinopril 10mg',Vicodin prn\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:49 PM\n INVASIVE VENTILATION - STOP 08:18 PM\n rpt ct scan unchanged, tx'd 2 units PRBC, residual L arm weakness.\n Post operative day:\n POD#2 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.3\nC (99.1\n HR: 86 (64 - 101) bpm\n BP: 112/62(74) {84/49(60) - 112/85(88)} mmHg\n RR: 19 (11 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,806 mL\n 33 mL\n PO:\n 700 mL\n Tube feeding:\n IV Fluid:\n 1,381 mL\n 33 mL\n Blood products:\n 725 mL\n Total out:\n 1,875 mL\n 820 mL\n Urine:\n 1,740 mL\n 820 mL\n NG:\n Stool:\n Drains:\n 135 mL\n Balance:\n 931 mL\n -787 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Anxious, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Murmur: No(t) Systolic, No(t) Diastolic)\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 Neuro: Awake, A&Ox3 and F.C.\ns, MAE but with Left upper Ext weakness;\n Labs / Radiology\n 333 K/uL\n 10.6 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 10 mg/dL\n 106 mEq/L\n 139 mEq/L\n 30.3 %\n 7.8 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n 02:53 PM\n 02:01 AM\n WBC\n 9.3\n 10.5\n 10.1\n 7.8\n Hct\n 32.9\n 32.7\n 30.5\n 27.1\n 30.3\n Plt\n 444\n 507\n 438\n 333\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.6\n TCO2\n 24\n 23\n 26\n Glucose\n 146\n 136\n 133\n 99\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:8.7 mg/dL, Mg:1.6 mg/dL, PO4:3.1 mg/dL\n Imaging: : CT Head: Post-operative changes as described. New right\n frontal high attenuation extra- axial collection likely post-operative\n in nature.\n CT: head: no significant change, slight incr air fluid lvl in r\n sphenoid sinus\n Assessment and Plan\n ANEMIA, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), ANEURYSM, OTHER\n Assessment and Plan: 51F s/p craniectomy/clipping of MCA aneurysm\n Neurologic: s/p elective clipping R MCA aneurysm; Q2hr check, head CT\n postop unchanged. Continues to have some L arm weakness. keppra PO,\n increase dilaudid prn for uncontrolled pain so far\n Cardiovascular: goal SBP <160, lisinopril PO, hydral PRN\n Pulmonary: s/p extubation, no issues\n Gastrointestinal / Abdomen: Regular diet, tolerating\n Nutrition: Regular diet\n Renal: UOP adequate\n Hematology: Hct trending down, 30.7 from 27 received 2 units\n Endocrine: RISS, fingersticks with good control\n Infectious Disease: No Abx, afebrile, WBC normal\n Lines / Tubes / Drains:\n Wounds: C/D/I, JP DC'd\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: Respiratory Insufficiency Post-op; CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines: d/c foley\n 18 Gauge - 05:22 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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 12 minutes\n" }, { "category": "Nursing", "chartdate": "2123-12-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 649370, "text": "HPI: 51F who initially presented w/ HA -> SAH s/p coiling of\n basal tip aneurysm, L frontal ventriculostomy on , then found to\n have vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis.\n Presents for elective Rt Crani for R MCA Aneurysm Clipping\n x2. Of note, sig clamp time of R MCA.\n PMH: Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n To SICU for postop monitoring\n Transfer to floor ?\n Aneurysm, other\n Assessment:\n - pt alert and oriented X3\n - Slightly weaker on Left side upper and lower extremities\n - Complaint of nausea\n Action:\n - Neuro checks changed to q4h\n - advanced diet to regular as tolerated\n - OOB to chair\n - Given zofran 2mg\n Response:\n - neuro status unchanged throughout shift\n - tolerates diet well, feeds self\n - complains of some jaw pain when having to chew food\n - steady on feet, requires supervision while transferring OOB\n - good response from zofran, currently denies nausea\n Plan:\n - order soft foods for meals\n - continue to get OOB\n - continue to assess neuro status and strength of extremities\n Pain control (acute pain, chronic pain)\n Assessment:\n - Pt complains of headache throughout shift\n Action:\n - Pain control regimen changed to dilaudid IV 0.5-2.5mg IV q2h\n Response:\n - Pt reports better pain control\n Plan:\n - continue to assess for and treat pain\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CEREBRAL ANEURYSM/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 67 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Precautions: Contact\n PMH:\n CV-PMH: Hypertension\n Additional history: ischemic colitis, coiling of basilar tip aneurysm,\n heartburn, elevated platelet count, sah with hydrocephalus, vent drain,\n vasospasm, headaches, mrsa\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:67\n Temperature:\n 98.8\n Arterial BP:\n S:121\n D:75\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 50 mL\n 24h total out:\n 1,490 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 02:01 AM\n Potassium:\n 3.7 mEq/L\n 02:01 AM\n Chloride:\n 106 mEq/L\n 02:01 AM\n CO2:\n 27 mEq/L\n 02:01 AM\n BUN:\n 10 mg/dL\n 02:01 AM\n Creatinine:\n 0.6 mg/dL\n 02:01 AM\n Glucose:\n 99 mg/dL\n 02:01 AM\n Hematocrit:\n 30.3 %\n 02:01 AM\n Finger Stick Glucose:\n 151\n 09:00 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: \n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2123-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649252, "text": "HPI: 51F who initially presented w/ HA -> SAH s/p coiling of\n basal tip aneurysm, L frontal ventriculostomy on , then found to\n have vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis.\n Presents for elective Rt Crani for R MCA Aneurysm Clipping\n x2. Of note, sig clamp time of R MCA.\n PMH: Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n To SICU for postop monitoring\n Transfer to floof\n Aneurysm, other\n Assessment:\n - pt alert and oriented X3\n - Weak on Left side upper and lower extremities\n - DP and DT pulses present bilaterally\n Action:\n - Neuro checks changed to q4h\n - advanced diet to regular as tolerated\n Response:\n - neuro status unchanged throughout shift\n - strength on left side improving throughout the day, now only\n slightly weaker than Right\n - tolerated diet well, feeds self\n - complains of some jaw pain when having to chew food\n Plan:\n - ordered soft foods for dinner\n - continue to assess neuro status and strength of extremities\n Pain control (acute pain, chronic pain)\n Assessment:\n - Pt complains of headache throughout shift\n Action:\n - dilaudid 2-4mg PO q4h PRN\n - Dilaudid 0.5-2mg IV q3h PRN\n Response:\n - Pt reports short term pain relief from 4mg dilaudid PO q4h\n - also requires -.5-1mg dilaudid IV between doses\n Plan:\n - continue to assess for and treat pain\n - continue frequent turning/repositioning\n Anemia, other\n Assessment:\n - pt hematorcit decreased from 30.5 to 27.1\n Action:\n - giving pt 2 units PRBC over 3 hours and checking HCT one\n hour after completion\n Response:\n - awaiting response\n Plan:\n - monitor pt while receiving blood products\n - continue to closely monitor Hematocrit level\n" }, { "category": "Physician ", "chartdate": "2123-12-03 00:00:00.000", "description": "Intensivist Note", "row_id": 649099, "text": "SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2.\n Chief complaint:\n s/p Rt Crani for R MCA Aneurysm Clipping x2\n PMHx:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD#0 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 100 mcg/Kg/min\n Nicardipine - 3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:30 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.1\n T current: 36.2\nC (97.1\n HR: 121 (88 - 121) bpm\n BP: 174/98(127) {156/92(119) - 209/128(161)} mmHg\n RR: 17 (13 - 17) insp/min\n Total In:\n 6,767 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,767 mL\n Blood products:\n Total out:\n 0 mL\n 8,245 mL\n Urine:\n 480 mL\n NG:\n Stool:\n Drains:\n 65 mL\n Balance:\n 0 mL\n -1,478 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n ABG: 7.40/37/329//0\n Ve: 8.4 L/min\n PaO2 / FiO2: 329\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : b/l), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated, Chemically paralyzed, postop sedation and\n paralyzed\n Labs / Radiology\n 444 K/uL\n 11.4 g/dL\n 32.9 %\n 9.3 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n WBC\n 9.3\n Hct\n 32.9\n Plt\n 444\n TCO2\n 24\n Other labs: Lactic Acid:4.1 mmol/L\n Assessment and Plan\n Assessment and Plan: 51yo F s/p Rt Crani for R MCA Aneurysm Clipping x2\n Neurologic: Neuro checks Q: 1 hr, s/p elective clipping R MCA aneurysm;\n Q1hr check, head CT @2100 , keppra, dilaudid prn, PPF gtt now\n Cardiovascular: goal SBP <160 on nicardipine gtt, lisinopril when\n taking PO\n Pulmonary: intubated, plan for extubation after paralyzation wears off\n Gastrointestinal / Abdomen: NPO for now\n Nutrition: NPO for now, sips and advance when extubated\n Renal: Foley, f/u UOP, replete lytes as needed\n Hematology: stable postop HCT\n Endocrine: RISS\n Infectious Disease: Vancomycin x2 doses postop\n Lines / Tubes / Drains: Foley, ETT, left femoral A-line, right VAD from\n angio to be removed. JP drain\n Wounds: C/D/I\n Imaging: CXR today, CT scan head today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:21 PM\n 16 Gauge - 05:22 PM\n 18 Gauge - 05:22 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2123-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649158, "text": "51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2.\n Aneurysm, other\n Assessment:\n Pt s/p elective clipping of 2 R MCA aneurysm. CT scan @ 2100 post\n crani showing no noted bleed. Pt neuro intact with noted L side\n weakness which pt states weakness the same pre-op. Otherwise very\n appropriate following commands. Pupil 2mm/brisk. Post op lactate\n 4.0/4.2. JP drain with moderate amts of s/s drng team is aware.\n Action:\n Pt extubated over noc. Cont with Q2hr neuro checks.\n Response:\n Pt neuro intact as stated above. Lactate trending down now 2.8. JP\n drainage decreasing.\n Plan:\n CT scan sometime today. Cont Q2 neuro ? tnf to stepdown or floor\n" }, { "category": "Physician ", "chartdate": "2123-12-06 00:00:00.000", "description": "Intensivist Note", "row_id": 649481, "text": "SICU\n HPI:\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n .\n PMH: Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n .\n : Keppra 1500mg\", Lisinopril 10mg',Vicodin prn\n .\n EVENTS.\n : admit to SICU intubated/sedated. Paralytic wearing off. CT Head\n done 4hr postop. Extubated early AM\n :rpt ct scan unchanged, tx'd 2 units PRBC, residual L arm\n weakness.\n : no beds available in stepdown, stayed in unit\n .\n MICRO:\n : MRSA positive\n .\n Imaging/Diagnostics:\n CT Head: Post-operative changes as described. New right frontal\n high attenuation extra- axial collection likely post-operative in\n nature.\n CT head: no significant change, slight incr air fluid lvl in r\n sphenoid sinus\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD#3 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:08 PM\n Heparin Sodium (Prophylaxis) - 12:59 AM\n Hydromorphone (Dilaudid) - 04:35 AM\n Other medications:\n Flowsheet Data as of 07:58 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: 36.3\nC (97.4\n HR: 58 (58 - 90) bpm\n BP: 114/62(76) {98/53(52) - 131/84(92)} mmHg\n RR: 7 (7 - 22) insp/min\n SPO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,350 mL\n PO:\n 1,300 mL\n Tube feeding:\n IV Fluid:\n 50 mL\n Blood products:\n Total out:\n 1,890 mL\n 500 mL\n Urine:\n 1,890 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -540 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 92%\n ABG: ///29/\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: 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: (Awake / Alert / Oriented: x 3), (Responds to: Verbal\n stimuli), No(t) Moves all extremities, (RUE: No(t) Weakness), (LUE:\n Weakness), (RLE: No(t) Weakness), (LLE: No(t) Weakness)\n Labs / Radiology\n 364 K/uL\n 10.8 g/dL\n 116 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 8 mg/dL\n 106 mEq/L\n 143 mEq/L\n 31.3 %\n 7.0 K/uL\n [image002.jpg]\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n 02:53 PM\n 02:01 AM\n 10:00 AM\n 11:00 AM\n 04:03 PM\n 01:30 AM\n WBC\n 10.5\n 10.1\n 7.8\n 7.9\n 7.0\n Hct\n 32.7\n 30.5\n 27.1\n 30.3\n 31.8\n 31.3\n Plt\n 45\n 364\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 23\n 26\n Glucose\n 136\n 133\n 99\n 53\n 155\n 116\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:9.5 mg/dL, Mg:1.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), ANEURYSM, OTHER\n Assessment and Plan:\n Neurologic: keppra, s/p mca vasospasm with left upper extr weakness\n Cardiovascular: lisinopril scheduled\n Pulmonary: IS, oob\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 01:04 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: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2123-12-04 00:00:00.000", "description": "Intensivist Note", "row_id": 649156, "text": "SICU\n HPI:\n 51F who initially presented w/ HA -> SAH s/p coiling of basal\n tip aneurysm, L frontal ventriculostomy on , then found to have\n vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis. Presents for elective Rt Crani for R MCA\n Aneurysm Clipping x2. Of note, sig clamp time of R MCA.\n Chief complaint:\n elective Rt Crani for R MCA Aneurysm Clipping x2\n PMHx:\n Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - START 05:21 PM\n INVASIVE VENTILATION - START 05:25 PM\n NASAL SWAB - At 05:27 PM\n OR RECEIVED - At 05:54 PM\n MULTI LUMEN - START 06:18 PM\n pt arrived to sicu with a single lumen central line in her right groin\n MULTI LUMEN - STOP 01:40 AM\n pt arrived to sicu with a single lumen central line in her right groin\n EXTUBATION - At 02:30 AM\n Post operative day:\n POD#1 - right parietal crani for clipping of two right mca aneurysms\n with post clipping angio\n Allergies:\n Codeine\n Nausea/Vomiting\n Penicillins\n Nausea/Vomiting\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Bactroban (Topical) (Mupirocin Calcium)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:20 AM\n Other medications:\n Flowsheet Data as of 05:21 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: 36.6\nC (97.9\n HR: 68 (68 - 121) bpm\n BP: 100/55(73) {85/51(62) - 209/128(161)} mmHg\n RR: 11 (0 - 25) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,020 mL\n 423 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,020 mL\n 423 mL\n Blood products:\n Total out:\n 9,345 mL\n 380 mL\n Urine:\n 1,480 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 165 mL\n 60 mL\n Balance:\n -1,325 mL\n 43 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): 486 (450 - 486) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SPO2: 94%\n ABG: 7.36/45/194/25/0\n Ve: 7 L/min\n PaO2 / FiO2: 388\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 : slightly b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\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), (Responds to: Verbal\n stimuli), No(t) Moves all extremities, (LUE: Weakness), weak LUE, moves\n all other extremities\n Labs / Radiology\n 438 K/uL\n 10.1 g/dL\n 133 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 30.5 %\n 10.1 K/uL\n [image002.jpg]\n 05:43 PM\n 05:54 PM\n 10:35 PM\n 10:42 PM\n 02:10 AM\n 02:21 AM\n WBC\n 9.3\n 10.5\n 10.1\n Hct\n 32.9\n 32.7\n 30.5\n Plt\n 444\n 507\n 438\n Creatinine\n 0.5\n 0.6\n 0.6\n TCO2\n 24\n 23\n 26\n Glucose\n 146\n 136\n 133\n Other labs: PT / PTT / INR:12.0/21.4/1.0, Lactic Acid:2.4 mmol/L,\n Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Assessment and Plan: 51yo F s/p elective Rt Crani for R MCA Aneurysm\n Clipping x2\n Neurologic: s/p elective clipping R MCA aneurysm; Q1hr check, head CT\n postop done. keppra PO, dilaudid prn, plan for CT head in PM to\n r/o stroke --d/w neurosurg when want to do scan\n Cardiovascular: goal SBP <160, nicardipine gtt off, lisinopril PO\n Pulmonary: s/p extubation, no issues\n Gastrointestinal / Abdomen: no issues.\n Nutrition: sips and advance to regular diet\n Renal: Foley, Adequate UO\n Hematology: f/u postop HCT, trending down. +JP drainage\n Endocrine: RISS\n Infectious Disease: vanc x2doses postop\n Lines / Tubes / Drains: Foley, left femoral A-line (unable to get\n radial/brachial a-line preop)\n Wounds: right groin w/o hematoma\n Imaging: CT scan head today\n Fluids: KVO once taking adequate PO\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:21 PM\n 16 Gauge - 05:22 PM\n 18 Gauge - 05:22 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2123-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 649243, "text": "HPI: 51F who initially presented w/ HA -> SAH s/p coiling of\n basal tip aneurysm, L frontal ventriculostomy on , then found to\n have vasospasm of ant & post circ s/p IA verapamil & on HHH\n therapy, meningitis.\n Presents for elective Rt Crani for R MCA Aneurysm Clipping\n x2. Of note, sig clamp time of R MCA.\n PMH: Diffuse SAH, Hydroceph, s/p fusiform basilar tip aneurysm, w/2\n saccular aneurysms involving the rt MCA, 3 mm aneurysm arising from L\n ICA, s/p coiling , h/o multiple cerebral aneurysms; uncontrolled\n HTN, smoker, h/o ischemic colitis (no surgery)\n To SICU for postop monitoring\n Transfer to floof\n Aneurysm, other\n Assessment:\n - pt alert and oriented X3\n - Weak on Left side upper and lower extremities\n - DP and DT pulses present bilaterally\n Action:\n - Neuro checks changed to q4h\n - advanced diet to regular as tolerated\n Response:\n - neuro status unchanged throughout shift\n - strength on left side improving throughout the day, now only\n slightly weaker than Right\n - tolerated diet well, feeds self\n - complains of some jaw pain when having to chew food\n Plan:\n - ordered soft foods for dinner\n - continue to assess neuro status and strength of extremities\n Pain control (acute pain, chronic pain)\n Assessment:\n - Pt complains of headache throughout shift\n Action:\n - dilaudid 2-4mg PO q4h PRN\n - Dilaudid 0.5-2mg IV q3h PRN\n Response:\n - Pt reports short term pain relief from 4mg dilaudid PO q4h\n - also requires -.5-1mg dilaudid IV between doses\n Plan:\n - continue to assess for and treat pain\n - continue frequent turning/repositioning\n" } ]

[ { "category": "Nursing/other", "chartdate": "2159-10-30 00:00:00.000", "description": "Report", "row_id": 1546219, "text": "11p-7a:\nneuro: sedated on propofol gtt, responds to painful stimuli. right pupil perrl, left pupil with cataract extraction. non-english speaking, daughter will translate.\n\ncv: a paced at 92, junctional in the 50's underlying. rare pvc's noted. sbp labile, requiring volume initially. currently with sbp > 90, map > 60 on levophed gtt. continues with epi gtt at same rate. ci> 2. see carevue for filling pressures. easily palpable pedal pulses bilaterally.\n\nresp: lungs clear, diminished bilateral bases. remains orally intubated on simv 40% 600 x 14, . abg wnl. ct to 20 cm sxn, no airleak. increased drainage noted with turning, pa aware. o2sat 99-100%.\n\ngi/gu: abd obese, bs absent. carafate and ppi. ogt to lws, minimal drainage. foley to gravity, good huo. cr 0.9.\n\nendo: regular insulin gtt titrated to off for bg 70's, will follow.\n\nplan: monitor hemodynamics, wean to extubate.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-10-30 00:00:00.000", "description": "Report", "row_id": 1546220, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnight. BP labile, on levo. BS's diminished w/ some coarseness. Sxing thick white secretions. No RSBI completed, secondary to no spont resps. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-10-30 00:00:00.000", "description": "Report", "row_id": 1546221, "text": "Neuro: A&O X3 via interpetor, IS, cough/DB teaching done via interpretor with good results, MAE's well, OOB X1 to chair with max assist of 2, lift back to bed D/T weak and unsteady, medicated with MSO4 2mg X2 and 1 percocet PO X1 with good effect for mediastinal/CT pain\nResp: weaned and extubated, currently on O2 at 6 LPm via NC with SPO2 > 92%, lungs clear but diminished at bases\nCardiac: 100% A paced D/T underlying rythm of ? junctional escape with , , SVo2 dropped signifcantly with activity to the mid 30's-40's, pt recovered within 5 minutes to SVo2 of >60%, weaned off levo and epi this AM\nGI: tolerating liquids well, reglan IVP X 1 for GI upset with good effect, pt refusing solids at this time\nGU: foley to gravity draining clear yellow urine in quantities > 25cc/hr, lasix 20mg X1 with good results\nEndo: SSRI coverage per \nSocial: dtr called and updated on condition\nPlan: monitor labs and vitals and treat as indicated and as ordered,increase diet and activity as tolerated, ? deline in AM and transfer toFarr 2\n" }, { "category": "Nursing/other", "chartdate": "2159-10-30 00:00:00.000", "description": "Report", "row_id": 1546222, "text": "D/C'd SWAN\n" }, { "category": "Nursing/other", "chartdate": "2159-10-31 00:00:00.000", "description": "Report", "row_id": 1546223, "text": "Neuro: Difficult to assess pt's neuro status as he is Spanish speaking. He does understand some English words and uses hand gestures. Pt was conversing with daughter last pm. MAE and obeys commands. Pain treated with Morphine and Percocets last pm with relief. Left pupil non-reactive d/t cataract surgery.\n\nResp: Pt currently on 4L NC. Lungs relatively clear at apexes (a bit coarse on RUL) and dim at bases. Pt able to mobilize secretions to throat, but not to mouth to be suctioned. Performs IS with encouragement to 400. Pt has CT to lwcs draining minimal amt serosanguinous drainage per hour. No air leak noted.\n\nCV: Pt A Paced at 80. A wires sense inconsistently. V wires do not sense or capture. See carevue for settings. Rare PVC's. Underlying rhythm appears to be ventricular bigeminy. Pt had 7 beat run of v tach, pressure did not tolerate well. NP notified. Pedal pulses by Doppler. 98.9=T max. Pt's K>5 entire shift.\n\nGI/GU: Pt tolerating PO meds and sips of water. Diet ordered this am. Hypoactive BS. Pt voiding amber urine via Foley, 25-35 cc/hr.\n\nEndo: RISS per CSRU protocol.\n\nA/P: Pulmonary toilet. Pt needs much encouragement in this area. Pain management. OOB to chair and advance diet.\n" }, { "category": "Nursing/other", "chartdate": "2159-10-31 00:00:00.000", "description": "Report", "row_id": 1546224, "text": "7A-7P\nNEURO: Alert. Spanish speaking with minimal english vocabulary. Per interpreter services oriented to person and place only. Pupils unequal secondary to cataract surgery. L pupil nonreactive. MAE. Follows commands. PO Percocet for pain with good effect. Afebrile. OOB today with max 2 assist.\n\nCV: NSR with occasional PVCs. Lytes repleted prn. 2A/2V Epicardial wires intact, do not S/C appropriatley. Pacer off. PO Metoprolol started today. SBP 80-110's. Dopplerable pulses. HCT 26.\n\nRESP: LS clear, coarse at times, dimished in bases. 4L NC 02sat >95%. Congested non productive cough. Weak cough effort. Chest tubes d/c'd today without incident. IS/CDB encouraged. MDIs as ordered.\n\nGU/GI: Foley to gravity. IV Lasix started . BUN/CR wnl. ABD obese. +hypoactive BS. Tolerating sips of liquids. PPI for GI prophylaxis.\n\nENDO: FSBS coverage per CSRU protocol.\n\nPLAN: Monitor Blood pressure. Aggressive Pulmonary Toileting!!!!! Assess/treat pain.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-01 00:00:00.000", "description": "Report", "row_id": 1546225, "text": "77 YR. OLD MAN WITH H/O CAD WITH DILATED CARDIOMYOPATHY. CATH REVEALED MULTIPLE VESSEL DISEASE INCLUDING LM. ->CABG X3 & AVR. REQUIRED VOLUME, LEVO, & EPI POST-OP. ->EXTUBATED, SWAN D/C'D, & LEVO/EPI WEANED OFF. ->PACER OFF(V WIRES NOT WORKING/A WIRES NOT SENSING APPROPRIATELY). CT D/C'D. NEEDS VIGOROUS PULM. TOILETING.\n\nNEURO: SPANISH SPEAKING MAN. UNDERSTANDS VERY LITTLE ENGLISH. HARD TO ASSESS ORIENTATION D/T LANGUAGE BARRIER. FOLLOWS SIMPLE COMMANDS. COOPERATIVE WITH CARE MOST OF TIME.\n\nRESP: O2->4L NP. BS COURSE, BUT DIMINISHED AT BASES. O2 SAT 95-98% UNTIL 0630 THIS AM. O2 SATS 88%->DOES NOT APPEAR SOB(SLEEPING). DENIES PAIN. 40% FT ADDED. O2 SAT 96%. RR 16-24. IS 1Q1-2HRS. NON-PRODUCTIVE COUGH.\n\nCARDIAC: HR 57-72 SR WITH OCC.PAC'S & RARE PVC. BP 85-110/34-49. ~2330\nSBP 73. 2200 LASIX DOSE HELD D/T BORDERLINE BP. 500CC NS BOLUS GIVEN X1. MID STERNAL DSG WITH SM. AMT. OLD SEROSANG DRAINAGE. L. LEG DSG D&I. +BPPP. C/O INCISIONAL PAIN X2->MEDICATED WITH PERCOCET 1 TAB PO WITH GOOD EFFECT. HCT 26.2.\n\nGI: APPETITE POOR THUS FAR. ABD. OBESE. BS HYPOACTIVE. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 10-30CC/HR. HO AWARE.\n\nID: AFEBRILE. WBC 22. VANCO DONE.\n\nENDO: BS 139->124. COVERED PER SLIDING SCALE.\n\nAM LABS SENT.\n\nPLAN: CONT. WITH PULMONARY TOILET.\n WEAN O2 WHEN AWAKE.\n CHECK AM WBC/HCT-? CULURES/TRANSFUSION\n INCREASE DIET/ACTIVITY AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-01 00:00:00.000", "description": "Report", "row_id": 1546226, "text": "CSRU Progress Note\nS-\"Not \", \"pain pill\"\nO-Neuro-alert and oriented x3, very pleasant and cooperative. Understanding only alittle english, but enough to get accross what is bothering him. Receiving percocett 2 tabs q6hrs for incisional pain with good relief.\nCV-HR 59-80 AF with , MD aware. Tolerated lopressor 12.5mg po at 10am without change in SBP. Although after receiving lasix 20mg IVB SBP dropped to 72, asymptomatic. A/V epicardial wires in place testing with good vent capture/sense, atrial wires not tested d/t AF.\nResp-LS coarse thorughout with exp wheezes, strong congested NPC/swallowing sputum. O2 sats 92-98% on 4l np. Using IS with encouragement. HCT 26 receiving 1u PRBC.\nID afebrile but with WBC 20.7\nGU-foley d/c'd and voiding using condom cath without difficulty. Lasix 20mg IVB with fair diuresis.\nGI-Abd obese and distened, hypoactive BS. No appetite, not eating hardly at all. No c/o nausea.\nSkin-Sternal dressing changed incision approximated without drainage.\nMediastinal dressing changed with small amount of sang drainage.\nLeft leg incision steri-strip and ace wrap changed. Bilateral pedal pulses dop/dop feet cold. -\nAccess-RRA removed and 1PIV placed with much difficulty, possibly changed trauma line to TLC for 2.\nCode Status-Full\nSocial-daughter called and could not get a ride into the hospital but hopefully will come Fri after work. Pt was able to talk to daughter with portable phone.\nA/P-s/p CABG/AVR still having hypotension without symptoms.\nFollow HCT post transfusion, Goal to keep SBP >90. Encourage cough and deep breathe and IS. Keep O2 sats >92% and wean O2 as necc.\nContinue to keep pt and family aware of POC as discussed in multi disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2159-10-29 00:00:00.000", "description": "Report", "row_id": 1546217, "text": "hypothermic & oozing from line sites,ct's. increased bloody staining noted on sternal dsg with pink tinged gastric dng. warmed with bair hugger,protamine & platelets given w resolution. protonix added for gi protection. labile bp with low filling pressures,mild metabolic acidosis,mod. huo treated w lots volume(lr & prbc). hemodynamics & bp appear optimal w cvp ~ 10,pad 18-22. svo2 remains > 65% on epi as indicated. levo titrated for bp support.a paced for underlying junctional 50's->sr with lots pac's in the 60's. ectopy minimally responsive to elyte replacement but suppression seems better with increased atrial rate.remins sedated on propofol per dr. ,plan a.m. vent wean.ett advanced 2 cm,equal but coarse bs. suctioned for scant white. non english speaking,will require a translator. glucoses managed as indicated,see flow sheet.daughter is designated spokesperson & was updated via telephone.\n" }, { "category": "Nursing/other", "chartdate": "2159-10-29 00:00:00.000", "description": "Report", "row_id": 1546218, "text": "episodes of hypotension into the 70's with cvp ~ ,pad 18-25 requiring increased levo & t positioning. propofol dose dropped with little effect on blood pressure,some mouth movement noted but not fully awake as yet.discussed ,add'l volume infusing.continues to have great hemodynamic parameters/svo2,plan to begin slow epi wean as tolerated when bp is more stable.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-02 00:00:00.000", "description": "Report", "row_id": 1546227, "text": "7P-7A\nNEURO: Alert. Spanish speaking. Unable to assess orientation due to language barrier. Follows simple commands. MAE. Pupils unequal due to prior cataract surgery. L pupil nonreactive. No complaints of pain. Afebrile. Activity with 2 person assist.\n\nCV: Afib with PVCs. Lytes repleted prn. Metoprolol . SBP 80-120's. 1 units PRBC for HCT 26. Post transfusion HCT 29.8. 2A/2V epicardial wires attached to pacer. Dopplerable pulses bilat.\n\nRESP: LS coarse dimished at bases with exp whzs @ times. RR 10-20's. O2 sat >92% 4L NC. IS with encouragement. Nonproductive congested cough. CPT done. MDIs as ordered.\n\nGU/GI: Foley cath reinserted with adequate HUO. Lasix . CR wnl. ABD obese with + hypoactive BS. Poor appetite. PPI for GI prophylaxis.\n\nENDO: FSBS per CSRU protocol.\n\nPLAN: Continue aggressive pulmoary tolieting. Monitor BP. Transfer to 2. Encourage PO intake.\n" }, { "category": "Echo", "chartdate": "2159-10-26 00:00:00.000", "description": "Report", "row_id": 82118, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Evaluate for Valvular heart disease.\nHeight: (in) 66\nWeight (lb): 220\nBSA (m2): 2.08 m2\nBP (mm Hg): 110/70\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 10:35\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mildly dilated LV cavity. Moderately depressed LVEF. Cannot\nassess LVEF.\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left atrium is moderately dilated. The right atrium is moderately\ndilated.\n2. The left ventricular cavity is mildly dilated. Overall left ventricular\nsystolic function is at least moderately depressed. Overall left ventricular\nsystolic function (EF) cannot be reliably assessed.\n3. The right ventricular cavity is dilated. Right ventricular systolic\nfunction appears depressed.\n4. The aortic valve leaflets are moderately thickened. There is at least mild\naortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n" }, { "category": "Echo", "chartdate": "2159-10-29 00:00:00.000", "description": "Report", "row_id": 82088, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease.\nHeight: (in) 65\nWeight (lb): 220\nBSA (m2): 2.06 m2\nBP (mm Hg): 110/60\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 13:39\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nAortic valve and mitral valve pathology were read with Dr.\nLEFT ATRIUM: Depressed LAA emptying velocity (<0.2m/s)\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial\nseptum.\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction. Moderate-severe\nregional left ventricular systolic dysfunction. No LV mass/thrombus.\nModerately depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - hypo;\nseptal apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter. There are complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Moderate (2+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The rhythm appears to be\natrial fibrillation. Results were personally reviewed with the MD caring for\nthe patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrial appendage emptying velocity is depressed (<0.2m/s). There is\nmoderate SEC seen in the LAA and left atrium.\nThere is moderate regional left ventricular systolic dysfunction with LVEF\n30-35%. No masses or thrombi are seen in the left ventricle. Resting regional\nwall motion abnormalities include anterior and septal walls.\nThere is mild global right ventricular free wall hypokinesis.\nThere are complex (>4mm) atheroma in the descending thoracic aorta.\nThe aortic valve noncoronary cusp is severely thickened/deformed. by\ncontinuity is 1.2 to 1.3. The peak and mean gradients were 25 and 12mm of HG\nrespectively. Trace AI seen.\nThe mitral valve is thickened with no prolapse or flail segments. The\nposterior leaflet is retracted with an eccentric mitral regurgitant jet\nconsistent with moderate MR.\nPOST_BYPASS:(on epinephrine)\nOVERALL LVEF 35% to 40%.\nNormal RV systolic function. Mild improvement in previously mentioned\nsegmental wall m otions.\nAortic bioprosthesis is in place with pathological leaks. POST prosthesis\ngradients are a peak of 30 and a mean of 15mm of Hg.\nMitral ring is in position and is stable. Trace residual mitral regurgitation\nis seen. There may be a single high velocity periprosthetic leak seen. There\nis no post ring mitral stenosis.\nAortic contour is in place.\n\n\n" }, { "category": "ECG", "chartdate": "2159-10-29 00:00:00.000", "description": "Report", "row_id": 209261, "text": "Atrial fibrillation. No change since the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2159-10-28 00:00:00.000", "description": "Report", "row_id": 209262, "text": "Atrial fibrillation. Non-specific ST-T wave changes. No previous tracing\navailable for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2159-10-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 936231, "text": " 6:13 PM\n CHEST (PA & LAT) Clip # \n Reason: preop\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man with CAD. Preop.\n\n PA AND LATERAL CHEST RADIOGRAPH: There is no comparison. Note is made of\n cardiomegaly and tortuous aorta with calcification. There is bilateral\n pleural effusion, greater on the right. There are opacities in right lower\n lobe. Note is made of interstitial markings and vascular prominence\n bilaterally, most likely representing CHF.\n\n IMPRESSION: Cardiomegaly, vascular prominence in upper lobes and interstitial\n markings, and pleural effusion, most likely representing congestive heart\n failure. Opacity in right lower lobe, which probably represent atelectasis,\n however, pneumonia cannot be totally excluded. Clinical correlation is\n recommended.\n\n" }, { "category": "Radiology", "chartdate": "2159-10-25 00:00:00.000", "description": "TEETH (PANOREX FOR DENTAL)", "row_id": 936232, "text": " 6:14 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: preop for MVR, eval for infection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD, MR\n REASON FOR THIS EXAMINATION:\n preop for MVR, eval for infection\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old male with coronary artery disease, preop for MVR.\n\n PANORAMIC VIEW OF THE TEETH: There is no evidence of bone erosion or no\n evidence of lucency in the periodontal area. Maxillary sinuses are clear.\n\n IMPRESSION: No evidence of bone erosion. However, please note that the plain\n radiograph is not sensitive for subtle infection, and correlation with\n physical exam and clinical condition is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-10-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 936784, "text": " 3:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD/AS/MR s/p CABG/AVR/MV Repair\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG, AVR and MVR.\n\n Status post AVR/MVR. Endotracheal tube is 5 cm above carina. Tip of\n Swan-Ganz catheter overlies proximal right main pulmonary artery. Mediastinal\n and left chest tubes in situ. NG tube has tip located overlying body of\n stomach. No pneumothorax. Minimal atelectasis at left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937044, "text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx s/p CT d/c\n Admitting Diagnosis: CONGESTIVE HEART FAILURE; DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD/AS/MR s/p CABG/AVR/MV Repair\n\n REASON FOR THIS EXAMINATION:\n eval ptx s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:32 A.M., \n\n HISTORY: MR disease.\n\n IMPRESSION: AP chest compared to through 20:\n\n Postoperative widening of the cardiomediastinal silhouette is stable. Small\n right pleural effusion has increased. There is no pneumothorax or pulmonary\n edema. Right supraclavicular jugular introducer ends just above the junction\n of the brachiocephalic veins.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-11-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 937724, "text": " 2:10 PM\n CHEST (PA & LAT) Clip # \n Reason: eval effusions, CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD/AS/MR s/p CABG/AVR/MV Repair\n\n REASON FOR THIS EXAMINATION:\n eval effusions, CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of CABG with AVR and mitral valve repair.\n\n Status post CABG/AVR and MV repair. Cardiomegaly, but no change in heart size\n or mediastinal width since the previous film of . There are\n small bilateral pleural effusions with associated bibasilar atelectasis. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-10-26 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 936313, "text": " 10:13 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: CAD, BRUITS\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD\n REASON FOR THIS EXAMINATION:\n bruits\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE.\n\n REASON: Bruits.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaques identified.\n\n On the right, peak systolic velocities are 62, 102, and 84 in the ICA, CCA,\n and ECA respectively. The ICA to CCA ratio is 0.6. This is consistent with\n less than 40% stenosis.\n\n On the left, peak systolic velocities are 39, 79, and 101 in the ICA, CCA, and\n ECA respectively. The ICA to CCA ratio is 0.5. This is consistent with less\n than 40% stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-10-29 00:00:00.000", "description": "O CHEST (SINGLE VIEW) IN O.R.", "row_id": 936753, "text": " 1:17 PM\n CHEST (SINGLE VIEW) IN O.R.; -76 BY SAME PHYSICIAN # \n Reason: NEEDLE COUNT\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n HISTORY: Erroneous needle count.\n\n No surgical needles are identified on this film, which does not include the\n extreme lung apices or lateral portion of the right hemithorax. Endoscope, NG\n tube, Swan-Ganz catheter and left chest tube are noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-11-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 937432, "text": " 9:03 AM\n CHEST (PA & LAT) Clip # \n Reason: eval pleural effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p AVR, MVR CABG\n\n REASON FOR THIS EXAMINATION:\n eval pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: AVR, MVR, CABG, pleural effusions.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . Bilateral\n pleural effusions are present. The heart remains enlarged, consistent with\n prior surgery. Bilateral effusions are present. Some pulmonary plethora is\n seen suggesting a degree of failure.\n\n IMPRESSION: Bilateral effusions, evidence of failure.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2119-02-12 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1230543, "text": " 8:53 AM\n TRAUMA #2 (AP CXR & PELVIS PORT); -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Single portable chest and AP pelvis radiograph demonstrates\n unremarkable mediastinal, hilar and cardiac contours. There are bilateral low\n lung volumes with some crowding of the vessels, however, there appears to be\n asymmetric increased opacification of right lung, concerning for pulmonary\n contusions. Left lung is not well assessed due to overlying trauma board. No\n displaced rib fractures are evident on the right; right first rib fracture on\n outside hospital CT performed earlier today not well seen on this radiograph\n study. Displaced posterior rib fractures evident in ribs 3, 4 and 5 on the\n left. Bilateral chest tubes in place. No pneumothorax or pleural effusion\n evident on a single view. Endotracheal tube is 2 cm above the carina and\n should be withdrawn. Nasogastric tube courses below the level of the\n diaphragm, inferior aspect not seen, but likely courses into the stomach.\n\n Single AP view of the pelvis demonstrates comminuted, displaced fractures\n through the inferior and superior right pubic rami as well as two faint linear\n lucencies extending from the left sacroiliac joint into the sacrum, concerning\n for additional fractures. No sacroliac joint or pubic symphisis widening\n appreciated. Foley catheter projects over bladder shadow.\n\n IMPRESSION:\n 1. Displaced left rib fractures. Right first rib fracture better seen on\n CT.\n 2. Right-sided pulmonary opacifications concerning for pulmonary contusion.\n 3. No pneumothorax evident.\n 4. Right superior and inferior pubic rami and left sacral fractures, as above.\n\n" }, { "category": "Radiology", "chartdate": "2119-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230830, "text": " 3:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for PTX\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman s/p MVC with bilateral PTX now s/p left CT removal\n REASON FOR THIS EXAMINATION:\n assess for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 16-year-old woman status post motor vehicle collision with\n bilateral pneumothorax, now status post left chest tube removal.\n\n COMPARISON: at 5 a.m.\n\n PORTABLE AP CHEST RADIOGRAPH: In the interim since most recent prior\n examination, there has been removal of the left-sided chest tube. No\n pneumothoraces are visualized on today's study. Displaced left-sided rib\n fractures are noted. There is a resolving right apical contusion.\n\n" }, { "category": "Radiology", "chartdate": "2119-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230753, "text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with chest tube after MVC\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:01 A.M. ON \n\n HISTORY: 16-year-old woman after motor vehicle collision with a chest tube.\n Rule out pneumothorax.\n\n IMPRESSION:\n AP chest compared to , 6:41 p.m.:\n\n There has been no interval change in the right apical juxtamediastinal\n contusion. There is no right pleural abnormality aside from mild thickening\n of the apical pleural margin. Multiple left posterior rib fractures,\n displaced but unchanged. Left pleural tube in place. No pneumothorax or\n pleural effusion. Heart size top normal, exaggerated by low lung volumes.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230709, "text": " 6:37 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PNX Please take xray at 7:00 pm. Thanks\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with s/p R CT dc'd\n REASON FOR THIS EXAMINATION:\n PNX Please take xray at 7:00 pm. Thanks\n ______________________________________________________________________________\n WET READ: PBec MON 8:49 PM\n interval removal of R CT, no pneumothorax developed. Otherwise unchanged exam.\n pbishop\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:41 P.M. ON \n\n HISTORY: 16-year-old after trauma. Chest tube removed.\n\n IMPRESSION: AP chest compared to :36 a.m.:\n\n There is no pneumothorax or detectable pleural effusion since :36 a.m.\n following removal of the right pleural tube. Left pleural tube still in\n place. Mild thickening of the right apical pleural margin has not changed.\n The right apical consolidation, most likely a pulmonary contusion is improved\n since 5 a.m., not much changed since :30 a.m. Heart size normal. Left lung\n clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-02-12 00:00:00.000", "description": "PELVIS (AP, INLET & OUTLET)", "row_id": 1230577, "text": " 3:07 PM\n PELVIS (AP, INLET & OUTLET) Clip # \n Reason: characterize pelvic fracture (R)-- PELVIS (AP, INLET & OUTLE\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman s/p MVC w/ R pelvic fracture\n REASON FOR THIS EXAMINATION:\n characterize pelvic fracture (R)-- PELVIS (AP, INLET & OUTLET)\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS\n\n REASON FOR EXAM: Evaluate pelvis fracture.\n\n There is a comminuted fracture, minimally displaced, of the inferior and\n superior right pubic ramus. A vertical sacral fracture is difficult to\n evaluate. There is no evidence of dislocation or osteolytic or osteoblastic\n osseous lesions.\n\n" }, { "category": "Radiology", "chartdate": "2119-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230611, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with bilateral chest tubes, intubated from MVC\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5 A.M. ON \n\n HISTORY: Bilateral pleural tubes. Intubated.\n\n IMPRESSION: AP chest compared to , 8:40 a.m., read in conjunction with\n chest CT :\n\n Mild edema present on has cleared, but there is still a large area of\n consolidation in the right lung posterior to the right hilus and alongside the\n upper mediastinum, but whether this is all due to trauma or to intrusion by\n largely fissural right pleural tubes radiographically indeterminate. Small\n amount of pleural or extrapleural fluid thickens the apical pleural margin of\n the right lung, and this may be an acute change. Careful followup is advised.\n CT scan preceded the placement of the left pleural tube whose location is\n impossible to assess on the frontal view. Small left apical pneumothorax\n amidst multiple posterior rib fractures, unchanged. No appreciable pleural\n effusion. Heart size is normal, but the contours of the upper mediastinum are\n distorted by adjacent pulmonary abnormality as described.\n\n Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230645, "text": " 10:49 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: see if PTX larger now on water seal\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with bilat PTX s/p bilat CT. now on water seal\n REASON FOR THIS EXAMINATION:\n see if PTX larger now on water seal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:36 A.M., \n\n HISTORY: Woman with bilateral pneumothorax. On waterseal.\n\n IMPRESSION: AP chest compared to , 5:00 a.m.:\n\n Lung volumes have improved. Asymmetric pulmonary edema has almost resolved.\n There may also be some improvement in the right perihilar consolidation or\n contusion. Tiny left apical pneumothorax is stable and no pleural effusion\n evident, bilateral pleural tubes still in place, including the right tube\n which was shown as fissural on recent chest CT, , performed elsewhere.\n\n" }, { "category": "ECG", "chartdate": "2119-02-14 00:00:00.000", "description": "Report", "row_id": 245433, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2119-02-14 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1230865, "text": " 8:41 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: C spine ligament injuty\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16F unrestrained passenger pickup truck. +LOC. + Cervical tenderness.\n REASON FOR THIS EXAMINATION:\n C spine ligament injuty\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 16-year-old female with unrestrained MVA. Assess for ligamentous\n injury in the setting of cervical tenderness.\n\n COMPARISON: None available for comparison.\n\n TECHNIQUE: Sagittal STIR, diffusion-weighted images, T1 and T2 images as well\n as axial gradient echo and T2 sequences were obtained without contrast.\n\n FINDINGS: The cervical spine is slightly straightened. Vertebral body\n height, bone marrow signal, and alignment are unremarkable. The\n intervertebral discs demonstrate preservation of height and T2 signal. There\n is no abnormal signal involving the para- and inter-spinous ligaments.\n\n At C5/C6, there is a minimal central disc protrusion, contacting the anterior\n cord surface.\n\n At C6/C7, an annular tear is associated with mild central disc protrusion,\n contacting and minimally deforming the anterior cord surface.\n\n There is no evidence of disc herniation or neural foraminal narrowing.\n\n The craniocervical junction is normal. Besides the above-mentioned areas of\n mild cord remodeling, the cervical cord has normal morphology and preserved\n intrinsic T2 signal. There is no diffusion abnormality.\n\n Incidental note is made of prominent adenoid tissue.\n\n IMPRESSION:\n 1. No evidence of fracture or ligamentous injury.\n\n 2. Relatively mild degenerative changes involving C5/C6 and C6/C7 segments\n with small central disc protrusions and minimal cord remodeling.\n\n" }, { "category": "Radiology", "chartdate": "2119-02-14 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2-3 VIEWS", "row_id": 1230867, "text": " 8:57 PM\n C-SPINE NON-TRAUMA VIEWS; T-SPINE Clip # \n Reason: please do a swimmer's+ view of cervico-thoracic junction\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with arm pain\n REASON FOR THIS EXAMINATION:\n please do a swimmer's+ view of cervico-thoracic junction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 16-year-old with neck and arm pain.\n\n These two examinations consist of seven images of the cervical and thoracic\n spine. No abnormality is identified. No fracture or bone destruction and\n normal vertebral body alignment. No prevertebral soft tissue swelling.\n Prominence of the posterior superior soft tissues in the pharynx are normal\n adenoidal tissue in this age group. Visualized lung apices clear.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2112-08-02 00:00:00.000", "description": "Report", "row_id": 66716, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Chest pain. Shortness of breath.\nHeight: (in) 70\nWeight (lb): 240\nBSA (m2): 2.26 m2\nBP (mm Hg): 103/50\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 12:12\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.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD by 2D or color\nDoppler. Dilated IVC (>2.5 cm), with minimal respiratory variation c/w\nelevated RA pressure of >20 mmHg. Dilated IVC (>2.5 cm).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF. No resting LVOT gradient. No LV mass/thrombus. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. Moderate [2+] TR. Borderline PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nNo atrial septal defect is seen by 2D or color Doppler. The inferior vena cava\nis dilated (>2.5 cm). 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 low normal (LVEF 50-55%). No masses or\nthrombi are seen in the left ventricle. There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened\nbut aortic stenosis is not present. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild to moderate (+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\nThere is borderline pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2112-08-04 00:00:00.000", "description": "Report", "row_id": 143629, "text": "Atrial fibrillation\nModest nonspecific ST-T wave changes\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2112-08-01 00:00:00.000", "description": "Report", "row_id": 143630, "text": "Atrial fibrillation with an average ventricular response, rate 110. Since the\nprevious tracing of the electrocardiogram is unchanged.\n\n" }, { "category": "ECG", "chartdate": "2112-07-31 00:00:00.000", "description": "Report", "row_id": 143631, "text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of atrial fibrillation has appeared and there are non-specific\nT wave abnormalities.\n\n" }, { "category": "ECG", "chartdate": "2112-07-28 00:00:00.000", "description": "Report", "row_id": 143632, "text": "Ectopic atrial rhythm, new since the previous tracing of . No other\nchanges. No other diagnostic abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2112-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926429, "text": " 2:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infection, effusion\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with fever, confusion, and no localizing source. New\n tachypnea\n REASON FOR THIS EXAMINATION:\n eval for infection, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever, confusion, tachypnea.\n\n CHEST: AP film and poor lung volumes probably exaggerate the cardiac size\n which is, however, I believe enlarged. No gross failure is seen. The\n costophrenic angles are sharp.\n\n Allowing for differences in technique, there has been no significant change\n since the prior chest x-ray.\n\n IMPRESSION: No change.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-07-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 926469, "text": " 11:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please scan when patient is getting CTA performed. Thank you\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with mental status changes without known etiology\n REASON FOR THIS EXAMINATION:\n Please scan when patient is getting CTA performed. Thank you. *\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 77-year-old male with change in mental status.\n\n COMPARISON: , and .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, shift of normally\n midline structures, mass effect, hydrocephalus, or major vascular territorial\n infarction. The ventricles, sulci, and basal cisterns are symmetric. The\n /white matter distinction is preserved. A small well-marginated hypodense\n focus of the subinsular cortex on the left is consistent with a remote lacunar\n infarct. There is mild ethmoid sinus mucosal thickening. The surrounding\n soft tissues are unremarkable. A fixation plate transfixes an old left\n zygomatic fracture.\n\n IMPRESSION: No intracranial hemorrhage, mass effect, hydrocephalus, or other\n acute pathology identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-07-31 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 926470, "text": " 11:05 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: please perform CT with contrast for dissection protcol.\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with altered mental status, wide mediastinum. Concern for\n possible dissection\n REASON FOR THIS EXAMINATION:\n please perform CT with contrast for dissection protcol.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 77-year-old male with change in mental status and widened mediastinum with\n concern for aortic dissection.\n\n COMPARISON: CT chest .\n\n TECHNIQUE: MDCT continuously acquired axial images of the chest, abdomen, and\n pelvis were obtained without IV contrast followed by axial images of the chest\n and abdomen after a rapid bolus of 100 mL Optiray IV contrast per the\n dissection protocol.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: This study is significantly\n limited by patient motion and suboptimal timing of the contrast bolus. The\n aortic root is mildly prominent at 3.6 cm but there is no evidence of frank\n aneurysm. There are calcifications of the aortic arch and coronary arteries.\n There is no evidence of aortic dissection or central pulmonary embolism. There\n is a small pericardial effusion including a small amount of fluid in the\n superior pericardial recess. There is prominent mediastinal fat likely\n corresponding to the widened appearance of the mediastinum on chest\n radiographs. Multiple small mediastinal lymph nodes do not meet CT criteria\n for pathologic enlargement. There is mild apical scarring and posterior\n dependent atelectatic changes. There are minimal bilateral pleural effusions.\n No focal consolidation or pneumothorax is identified. The airways are patent\n to the subsegmental level bilaterally.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Evaluation of the abdomen is\n significantly limited by patient motion and streak artifact. Given this\n limitation, the liver, pancreas, spleen, adrenal glands, gallbladder, stomach,\n duodenum, and intra-abdominal loops of bowel are unremarkable. A 2.7-cm low-\n density lesion of the right renal upper pole is likely a cyst. Smaller right\n renal lesions are not well evaluated due to streak artifact. There is no free\n intra- abdominal air or gas.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter within the\n urinary bladder which is decompressed. The prostate is enlarged. A 3.8 cm\n low density cystic appearing focus of the right prostate causes a contour\n bulge. The rectum and pelvic loops of bowel are unremarkable. There is no free\n pelvic fluid.\n\n BONE WINDOWS: There are extensive degenerative changes of the spine but no\n (Over)\n\n 11:05 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: please perform CT with contrast for dissection protcol.\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n suspicious lytic or sclerotic osseous lesions are identified.\n\n IMPRESSION:\n 1. Prominent mediastinal fat likely corresponds to the widened appearance of\n the mediastinum on chest radiograph. On this study limited by patient motion\n artifact and suboptimal contrast bolus timing, there is no evidence of aortic\n dissection, aneurysm, or central pulmonary embolism.\n\n 2. Posterior dependent atelectatic changes and minimal bilateral pleural\n effusions.\n\n 4. Right renal lesions incompletely characterized, but likely cysts.\n\n 5. Prostatic enlargement. 3.8 cm cystic area of right prostate is of\n uncertain signficance and clinical correlation is suggested.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-07-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 926288, "text": " 4:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o mass effect or bleed\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with HTN and hyperlipidemia admitted with fever and confusion.\n REASON FOR THIS EXAMINATION:\n r/o mass effect or bleed\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizure and confusion.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT INTRAVENOUS CONTRAST: The study is markedly limited secondary\n to patient motion and inability to cooperate with the exam. Within the limits\n of the study, no large gross intracranial hemorrhage is demonstrated. There\n is no large gross mass or shift of midline structures. Ventricles appear\n stable in size, without hydrocephalus. Moderate mucosal thickening is\n demonstrated within the right maxillary sinus. The patient is status post\n left maxillary and left mandibular surgery with plates and screws noted.\n\n IMPRESSION: Severely limited evaluation. No large gross intracranial\n hemorrhage identified.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2112-07-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 926158, "text": " 5:04 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with chest pain, fever\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain and fever. Evaluate for pneumonia.\n\n Comparison is made to chest radiograph of and CTA of , .\n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: Since , there is\n increase in heart size, now representing moderate cardiomegaly. The aorta is\n slightly tortuous. Hilar regions appear unremarkable. No consolidations are\n seen. The left cardiophrenic angle was not included in this study. The right\n cardiophrenic angle is clear. No pulmonary edema is seen.\n\n There is DISH of the thoracic spine.\n\n IMPRESSION:\n 1. Cardiomegaly without evidence of CHF.\n 2. No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926531, "text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for any infiltrates or consolidations\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with fever, confusion and ongoing tachypnea with wheezing\n\n REASON FOR THIS EXAMINATION:\n Please evaluate for any infiltrates or consolidations\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever, confusion, ongoing tachypnea.\n\n CHEST: There has been no significant change since the prior chest x-ray. No\n infiltrates or definite failure is seen. Some mild upper zone redistribution\n may, however, be present.\n\n IMPRESSION: No change, some upper zone redistribution likely present.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926354, "text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o interval process\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with fever, confusion, and no localizing source.\n\n REASON FOR THIS EXAMINATION:\n r/o interval process\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever, confusion.\n\n CHEST: The heart is somewhat enlarged. There is unwinding of the aorta but\n there is no evidence of failure and the lung fields are clear. The\n costophrenic angles are sharp.\n\n IMPRESSION: Stable cardiomegaly. No pneumonia, no failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-08-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 926555, "text": " 12:21 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Tip location of Right Cephalic PICC line\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with fever, confusion and ongoing tachypnea with wheezing\n\n REASON FOR THIS EXAMINATION:\n Tip location of Right Cephalic PICC line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever, confusion, tachypnea, PICC line placed.\n\n CHEST: The tip of the PICC line is difficult to see but it can be traced as\n far as the right atrium. The tip is obscured by the overlying spine shadows.\n\n The heart is enlarged. No failure or infiltrate is present.\n\n IMPRESSION: PICC line within right atrium, possibly extending into the right\n ventricle.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-08-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 926708, "text": " 2:35 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with fever and AMS. crackles on exam.\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, altered mental status, crackles. Evaluate for pneumonia.\n\n PA AND LATERAL CHEST: Compared to . Right-sided PICC line with its\n tip at the atriocaval junction. Heart is moderately enlarged, unchanged from\n prior studies. No evidence of congestive heart failure. Prominent epicardial\n fat pad. There is blunting of the CP angles.\n\n IMPRESSION:\n 1) Satisfactory PICC placement.\n 2) Cardiomegaly with probable small bilateral pleural effusions; no overt\n congestive heart failure.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-08-02 00:00:00.000", "description": "Report", "row_id": 1460218, "text": "Nursing note\nS-\"What station is this? What time is our train.\"\nO-see flowsheet for addtional details.\n\nN-agitated/ox1 most of night. attempting to get OOB. Unable to understand concept of foley demanding he needed to get up to urinate. Requiring frequent re-orientation to place and time. Olanzipine @ HS. Benzos held as ordered. <10. Denies pain. Minimal sleep. Sitter required at bedside all of shift. Occasionally attempting to pull at foley/lines.\n\nCV-continues in a-fib c poor rate control 100-140 despite lopressor/amnio. 0000 PTT >150. heprin gtt held as ordered and decreased to 950unis/hr. am labs pending. PICC and PIVs WNL. Unable to keep K pad on PICC c pt's agitation. SBP 90-117 c MAP >65.\n\nResp-COntinues to be tachypnic up to 30 c exp wheezes. Although tachypnic denies difficulty breathing. Nebs as ordered c some results. flonase @ HS c spacer. NC 2L c sats >96%. NP.\n\nID-broad spectrum abxs dosed. afebrile this shift. c am temp pending.\n\nGI/GU-BS hypoactive. -BM. tolerating diet per previous shift. no difficulty swallowing pills. UO WNL, yellow c sediment. Foley leaking-replaced c 16French cath. Pt tolerated well.\n\nSkin-PICC, PIVs wnl. otherwise intact.\n\na/p-77y.o male admitted c complaints of a cold and chest. pt was transferred to MICU c fever, MS changes, tachypnea, and onset of a-fib. Fever of unknown origin as all cultures negative thus far. Continue to monitor temps, WBCs, cxs, abxs and source of fevers. Monitor MS . COnsider sitters at night for pattern of \"sun-downing\", continue amnio and lopressor nodal agents. Adjust heprin per PTT. Update pt and family s/p interdisiplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-02 00:00:00.000", "description": "Report", "row_id": 1460219, "text": "Transfer Note\nCV: 89-120's, continues on PO amio, lopressor. HR 130's with neb tx. BP 95-120/60-70's. Bedside echo this afternoon. Heparin gtt infusing Ptt subtherapeutic and heparin gtt increased. Next ptt 2200. 1st dose coumadin to be given tonight.\nAccess: R cephalic dual lumen PICC placed .\nResp: BBS noted with occasional wheezes and crackles LLL. Continues on Q4hr neb tx per RT with improvement. Pt with congest non-productive cough. 2L NC, RR 17-29, sats >97%.\nNeuro: speaking and understands/speaks little english. Denies pain and states that he is in \"\", but unable to remember name of hospital. Oriented to self and date but \"sun-downs\" and starts to become restless/agitated in the evenings. Has attempted to climb OOB and pull lines. Sitter at bedside overnoc, but wife visiting during day and patient appropriate. Denies pain or trouble breathing\nGI/GU: Abdomen softly distended, BS hypoactive. Tolerating diet. Foley cath draining dark yellow-brown urine. No BM this shift.\nID: Vanco/flagyl d/c and continues on levoflox. Tmax 99.3. PA lateral xray performed.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-31 00:00:00.000", "description": "Report", "row_id": 1460213, "text": "Resp. Care\nPt. trans from floors due to tachycardia and tachypnea. Pt. was in A-FIB in the 140-150s with a RR 35-40. Sao2 97% on r/a. B/S are scat exp. wheezes. Neb was given at 0300 with min. effect. Pt. still wheezing post rx.Plan is to monitor and eval for further rx.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-31 00:00:00.000", "description": "Report", "row_id": 1460214, "text": "Pt is a 77 y/o male who presented to ED with chest pain and mental status changes. Had been in usoh until that evening he went for a walk and returned with cp and MS change. In pt found to be hypotensive (80's) which responded to fluid boluses. Pt also with dry cough. Adimtted to CC7 where he ruled out for MI. Pt did however suffer worsening mental status becomming very agitated and aggressive on floor. Head CT negative for bleed. Pt also spiking temps over 101 while on cc7. All culture data has returned negative. LP performed also negative. pt developed rapid afib and increased tachypnea to 40's. Abg showing resp alkalosis. Tx to MICU 6 for tx of RAF, tachypnea, and mental status changes of unknown origin.\n\nNeuro: Pt is speaking only. Orientation difficult to assess. Very restless and has pulled out multiple IV access since admission to hospital. Posey and soft wrist restraints intitiated. Medicated with 5mg Olanzapine and 0.5mg IV ativan with effect. Currently sleeping. Pt is occasionally redirectable by wife who is at bedside.\n\nResp: Lung sounds with wheezes bilaterally. RR 30-40's with use of accessory muscles and pursed lip breathing noted. Repeat ABG this am showing worsening resp alkalosis. Albuterol/atrovent neb given with marginal effect. O2 sats high 90's on 2L nc.\n\nCardiac: Received pt in rapid afib 130's-160's with no pvc's noted. Amiodarone load and gtt initiated with good effect on HR. Currently in 90's continues with afib however. Will have Echo today. Amiodarone gtt currently infusing at 1mg/min and will continue at this rate until 0900 when gtt will be titrated to 0.5mg/min.\n\nGI: Abd soft nontender. On house cardiac diet. Small guiac neg bm x1 on arrival.\n\nGU: Voided 75cc amber urine via urinal this shift. AM lytes pending.\n\nDerm: PIV in R hand patent. Pt is a very difficult stick and repeated attempts to place second access were unsuccessful. Skin otherwise intact.\n\nID: Tmax 101.5 Tcurrent 100.8. Pt is also quite diaphoretic. Vancomycin .\n\nSocial: Pt is speaking and has had wife at bedside throughout stay at hosp. She speaks little english but can intrepret a little for him. Daughter speaks english and is family spokesperson.\n\nPlan: Continue amiodarone gtt, pursue peripheral access (picc), monitor mental status and resp status, Support for family, social work consult.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-31 00:00:00.000", "description": "Report", "row_id": 1460215, "text": "Nursing Progress Note 0700-1900\n\nNeuro: Pt alert, mildly agitated, speaking only. Per daughter this AM, pt knows he is in the hospital and knows date. PEERLA, Moving all four extremities spontaneously. Responds to name when called. Given 5 mg PO Zyprexa, .5 mg IV Ativan prior to transfer to CT scan, during scan he became extremely agitated...attempting to sit up, straining at restraints, flailing around on CT table. Per daughter he was paranoid and \"thought that we were trying to kill him\".(Daughter shared that her father is a Holocaust survivor...referring to staff as Nazis). Given a total of 3 mg IV ativan in CT with no effect. Upon arrival back to the unit, sleeping, calm and responding to voice. EEG completed at bedside. CIWA scales have been unreliable.\n\nResp: Tachypneic this am with RR in 30's, lung sounds with expiratory wheezes at times. Nebs give by respiratory with some effect. Sats greater than 96 on 2 LNC. RR decreased mid 20's after recieving ativan. ABG from this afternoon 7.41/36/79. He has developed a congested, non-productive cough...?aspiration r/t being flat during prolonged attempt at CT.\n\nCardio: Afib with RVR on tele HR up to 130-140's while agitated. 90-110's when calm. Currently on amiodarone gtt load at .5 mg/min. Amio load due to be D/C'd at 0300. On PO lopressor and due to start PO amiodarone in AM. ECHO ordered. Trace lower extremity edema. Extremities warm palpable DP/PT bilaterally.Heparin gtt to be initiated as pt. has now been in AFib for >48hr.\n\nGI: Currently NPO, although he was able to take po meds this AM when more awake. Abdomen obese, soft and mildly distended. Hypoactive bowel sounds.\n\nRENAL: Foley placed today, draining moderate amounts of clear amber urine. At this writing +1100 for shift. Recived Sodium Bicarb hydration pre/post CT for dye load.\n\nID: T-Max 101.9 oral RX with tylenol and cool H2O/alcohol bath, currently afebrile. WBC pending from 1600. Repeat U/A and Lumbar puncture done today. Currently on Flagyl/Vanco/Levaquin. Vanco trough due in AM. Cultures to date have shown no growth.\n\nSkin: No current issues\n\nAccess: 3 PIV's. Difficult access. ? need for PICC/central line if patient continues on multiple IV medications.\n\nSocial: Wife at bedside most of the day. Daughter in to visit for a few hours this AM and speaks english.\n\nPlan:\n\n1. Continue to monitor temperature curve, WBC, Cultures, IV ANBX\n2. Monitor Mental Status, CIWA scale q 6 hours\n3. Continue on Amio gtt as ordered for AF. On heparin, PTT to be checked at midnight.\n4. Awaiting input from Neuro/ID\n5. Routine ICU montioring and care\n6. Emotional support to patient and family\n" }, { "category": "Nursing/other", "chartdate": "2112-08-01 00:00:00.000", "description": "Report", "row_id": 1460216, "text": "Neuro: Awake and alert. Somewhat lucid and speaking english. \"Where is my Wife?\"Medicated later in the shift for increased agitation and restlessness. Pt. pulled out Iv and swinging legs over side rails and yelling for water to drink. Med with Ativan and then Valium. Eventually fell into a sedative sleep shortly after Valium gien.\ncv/resp Afib. Rapid at aprox 2300. rate in the 150's. Bp stable. tachypnic with rr aprox 40. Very wheezy. Albuteral neb given and diltiazem total of 20mg given. Pt. noted to be febrile. 102 axillary. Tylenol given and blood culture sent. Afib more controlled rate with sedation and pt. falling off to sleep. Continues to be wheezy.\nAlso remains on iv amiodarone because pt. is unable to take po amiodarone when sedated. Also remains on Heparin gtt no change in rate/dose. right anticubital IV pulled out.\nGi/Gu Npo except ice chips. Pt. yelling for something to drink. Given ice chips only. foley to gravity. good hourly uop. no stools.\ninteg skin warm and dry.\nPlan : Continue plan of care. Monitor resp status,mental status and fevers. follow-up on blood cultures.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-01 00:00:00.000", "description": "Report", "row_id": 1460217, "text": "Shift Note 0700-1900\nCV: HR 100-120's, a-fib with no ectopy. Pt was on amio gtt >24hrs since unable to convert to PO amio d/t pt being lethargic. Around 1200, patient alert and able to swallow pills. PO amio given and IV amio stopped at 1600. Pt started on IV lopressor and dose increased for rate control. Heparin gtt for afib. Supratherapeutic this am with PTT >150. Gtt off for few hours until PICC line placed in case IV team was unsuccessful and central line had to be placed. Heparin restarted at 1300units once PICC placed and placement confirmed by CXR. Next PTT 1900.\n\nAccess: Pt with very limited access. IV team consulted for bedside PICC line. PICC placed and K-pad applied. Slight bleeding noted from site and surgifoam applied with good result. PIV x2; patent.\n\nResp: BBS with audible expiratory wheezing. RT has been given patient nebs throughout day (HR responsive to albuterol neb and will become tachy 130-140's for short period). Congested, non-productive cough.\n\nNeuro: Pt agitated and restless last evening and given zyprexa and prn ativan. Pt very lethargic this am and difficult to arouse. PO meds held. Around noon, patient alert and able to communicate with wife and take meds. Per wife, patient oriented. Pt speaking and speaks little broken english.\n\nGI/GU: Abdomen distended, BS hypoactive. Pt started on soft diet, tolerating well. Foley cath draining adequate UO (pink-tinged to amber in color with sediment). No BM this shift.\n\nID: Pt on broad-spectrum coverage. Temp spikes with unclear etiology. BC sent this am, prior BC (-), urine (-). Tmax this shift 100. Pt ordered for nasalpharn. swab for rapid respiratory viral cx. RT aware, but lab unable to perform test today so RT will cx patient tomorrow.\n\nSocial: Full code, wife present at bedside all day.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2155-06-26 00:00:00.000", "description": "GASTRIC EMPTYING STUDY", "row_id": 790455, "text": "GASTRIC EMPTYING STUDY Clip # \n Reason: POST PRANDIAL NAUSEA. HX DIABETES. ASSESS FOR GASTROPARESIS.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Twenty-three year old male with h/o insulin dependent diabetes\n mellitus, persistent nausea following meals.\n\n INTERPRETATION:\n\n Following the oral ingestion of a meal of radiolabeled egg-whites, the patient\n was placed supine beneath the gamma camera. Multiple anterior and posterior\n images of the tracer activity in the stomach and bowel were recorded for 60\n minutes.\n\n Region of interest analysis of the tracer activity in the stomach shows 52%\n emptying of the gastric contents over 26 minutes. Normal value is 50% in 50\n minutes. There is no evidence of reflux throughout the study.\n\n IMPRESSION: Rapid gastric emptying demonstrating 52% emptying over the first 26\n minutes. No evidence of reflux. /nkg\n\n\n , M.D.\n , M.D. Approved: TUE 8:25 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2155-06-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 793525, "text": " 11:55 AM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for infiltrates w/ PA and latera\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with DM, HTN, CHF. Came in with DKA, possible pulmonary\n infection as inciting event\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrates w/ PA and latera\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Congestive heart failure and diabetic ketoacidosis with suspected\n pulmonary infection.\n\n TECHNIQUE: PA & lateral chest.\n\n COMPARISON: .\n\n FINDINGS: Allowing for differences in technique and patient position, there\n is stable cardiac enlargement. Mediastinal contours are within normal limits.\n There are persistently increased interstitial markings. In the interval, there\n has been improvement in the previously described right basilar air space\n opacities, likely compatible with resolving pulonary edema. There are no\n pleural effusions.\n\n IMPRESSION: Interval improvement in right basilar air space opacities with\n persistently increased interstitial markings, compatible with resolving\n pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 793398, "text": " 3:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrates\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with DKA, DM, CHF, RF\n REASON FOR THIS EXAMINATION:\n please eval infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infiltrate followup.\n\n PORTABLE CHEST: Comparison is made to earlier films from 2:49 AM the same\n day.\n\n Lung volumes are slightly reduced. The cardiac silhouette is again prominent.\n Mediastinal and hilar contours are grossly unchanged.\n\n Current findings are fairly similar to those from earlier today. There is\n still diffuse increase in interstitial markings, with additional scattered\n foci of airspace infiltrate scattered throughout the right lung. No definite\n new pleural or parenchymal abnormalities are identified.\n\n IMPRESSION: No definite change from the film of earlier today.\n\n" }, { "category": "Radiology", "chartdate": "2155-06-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 793458, "text": " 12:54 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval position of peritoneal dialysis catheter\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with DM, ESRD, now with PD being retained in abdomen.\n REASON FOR THIS EXAMINATION:\n please eval position of peritoneal dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess position of peritoneal dialysis catheter.\n\n PORTABLE KUB: Comparison is made to prior study dated . The\n distal aspect of the peritoneal dialysis catheter is again identified in the\n left upper quadrant of the abdomen. A nonobstructive bowel gas pattern is\n noted.\n\n\n" }, { "category": "Echo", "chartdate": "2155-06-23 00:00:00.000", "description": "Report", "row_id": 67016, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.S/p Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 160\nBSA (m2): 1.90 m2\nBP (mm Hg): 140/75\nStatus: Inpatient\nDate/Time: at 14:12\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is moderate global left\nventricular hypokinesis. There is no resting left ventricular outflow tract\nobstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. The mitral valve supporting structures are normal.\nThere is no significant mitral stenosis. Mild (1+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. The tricuspid valve\nsupporting structures are normal. There is no triscupid stenosis. Moderate\n[2+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. The main\npulmonary artery and its branches are normal. No color Doppler evidence for a\npatent ductus arteriosus is visualized.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity is moderately dilated. There is moderate-to-severe\nglobal left ventricular hypokinesis (ejection fraction 30 percent). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are structurally normal. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate\n[2+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of ,\nthe left ventricular ejection fraction is lower.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-22 00:00:00.000", "description": "Report", "row_id": 1346897, "text": "micu npn 0700-1900\n\n23 year old man, micu day 2, ruled in for NSTEMI, PD 5xday\n\nreview of systems:\n\nneuro: sleeping when not stimulated, alert oriented times three, moves extrem equally, OOB to chair, oob to commode, steady on feet, dangling at bedside with supervision.\n\nCV; HR 80-90 SR/ST, no VEA, BP 120-130's/60's, increasing facial and peripheral edema. cont heparin gtt am PTT 44.9 hep increased to 1150 u\n5pm PTT redrawn.\n\nGU: cont PD, 1.5% alternate with 2.5% dialysate Q4, effluent clear lightyellow one fibrin clot in first drainage , c/o abd cramping RLQ pain when instilled with 2L fluid, resident discussed abd discomfort with the renal fellow and it was decided at the 4pm run to drain PD fluid and clamp PD catheter until 9pm. Voided x2 clear yellow urine\n\nRESP: cont O2 2L n/c with O2 sat >97%, breath clear upper airways crackles at bases.\n\nGI: diet advanced to clear liquids tolerated without nausea, 5pm diet advanced to cardiac/diabetic diet had light dinner no nausea, IV reglan 5mg TID before meals initiated, diarrhea x1 OB-\n\nSKIN: intact\n\nHEME: hct 23 transfusing with 2 units PRBC's\n\nACCESS: 2 peripheral IV's\n\nSOCIAL: father visited briefly this afternoon, mom is at home sick.\n\nPLAN: brittle diabetic follow fingersticks closely, PD as ordered, next run due at 9pm with 1.5% dextrose, follow i/o, weight, follow hct, called to medical floor with tele, transfer note written.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-23 00:00:00.000", "description": "Report", "row_id": 1346899, "text": "NURSING NOTE 7A-7P Review of Systems\nNEURO: Alert, oriented, pleasant and cooperative. Speech clear able to ambulate to stretcher for transport to X-ray. Steady gait. PERRLA, Afebrile, no seisure activity noted.\nC/V: NSR rate 80 to low 100's. Denies chest pain, continued on Heparin at 1300 units in AM, Heparin drip D'cd in afternoon. Started on Heparin SC. Pulses present. BP 140-150's/80-90's. Continues on antihypertensives, ECHO done to eval LV function.\nRESP: O2 on at 2L NC with Sats 97%. Sats dip to 80's on roomair. Lung sounds clear with exceptions of crackles at Lt base, nonproductive cough.\nGU: Voided X one in urinal clear yellow urine. Peritoneal Dialysis continues alternating with 1.5% and 2.5% dialysate dwelling for 2 hours (Unable to tolerate 2000ml, 1200ml tolerated.) Draining time one hour clear yellow fluid.\nGI: Abd firm and distended, softer after drainage. BS positive, mod amt liquid brown stool on commode after given lactulose 30cc given PO. NPO this after Midnight ? cardiac cath procedure.\nENDO. FS q 6 hours, controlled with sliding scale insulin. PM dose insulin Lantus increased from 10 to 20 units.\nPLAN: Called out to floor, supplies needed for Baxter cycler if sent to floor. ? Cardiac Cath planned for tommorrow. Patient called father and spoke on phone regarding cath, Father due in this afternoon. Continue to monitor Lytes and Glucose.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-23 00:00:00.000", "description": "Report", "row_id": 1346900, "text": "NURSING NOTE ADDENDUM: 1800 FS=387 10 units humalog insulin given as ordered MD aware. PD continues with difficultly draining fluid (very positional) Totally clear fluid as day progressed. Currently infusing 2.5% Dextrose solution to be clamped at 700 for a total of 1800 in. Father continues to visit with patient.\n" }, { "category": "Nursing/other", "chartdate": "2155-06-24 00:00:00.000", "description": "Report", "row_id": 1346901, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS A & O X3. PLEASANT, OBEYS COMMANDS WITHOUT DIFFICULTY. SPEECH CLEAR. MAE X 4- ABLE TO AMBULATE FROM CHAIR TO COMMODE AND DANGLE ON SIDE OF BED WITHOUT DIFFICULTY. STEADY GAIT. AFEBRILE. NO SEIZURE ACTIVITY NOTED. SENSITIVE TO BILATERAL FEET DUE TO NEUROPATHY.\n\nCV: NSR WITH NO SIGNS OF ECTOPY. HR 60-70'S. SBP > OR = TO 130'S. NO HYPER OR HYPOTENSIVE CRISIS NOTED. CONTINUES ON ANTIHYPERTENSIVE REGIMEN. PALPABLE PULSES TO BILATERAL RADIALS AND DORSALIS. DENIES ANY CHEST PAIN.\n\nRR: 2 LITERS O2 VIA NC. BBS= ESSENTIALLY CLEAR. NO COMPLAINTS OF SOB OR DYSPNEA. BILATERAL CHEST EXPANSION NOTED. SP02 > OR = TO 95%.\n\nGI/GU: NPO SINCE MIDNIGHT. ABDOMEN IS FIRM AND DISTENDED. BS X 4 QUADRANTS. NON-TENDER TO PALPATION. PT IS CURRENTLY ON PD ORDERED AS 2000L OF 2.5% DEXTROSE Q 2 HOURS. TOLERATING WELL- NO C/O OF N/V/D.\n\nINTEG: SO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nENDO: PT ON SLIDING SCALE. BLOOD SUGAR HAS BEEN HIGH 200'S. LENTIL GIVEN AS ORDERED.\n\nPLAN: HEART CATH TODAY. CONTINUE PD AS ORDERED. TRANSFER TO FLOOR.\nPLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-23 00:00:00.000", "description": "Report", "row_id": 1346898, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS VERY PLEASANT. COOPERATIVE. SPEECH CLEAR. ABLE TO AMBULATE, DANGLE AND GO FROM BED TO COMMODE WITHOUT DIFFICULTY. STEADY GAIT. PERRLA. 3/B. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nCV: NSR, S1 AND S2 AS PER AUSCULTATION. DENIES ANY CHEST PAIN. CONTINUES ON HEPARIN GTT- CURRENTLY AT 1300 UNITS/HR. PTT SENT WILL TITRATE AS PER HEPARIN PROTOCOL AS NEEDED. PALPALBE PULSES TO BILATERAL DORSALS AND RADIALS. PT IS VERY SENSITIVE TO FEET DUE TO NEUROPATHY.\n\nRR: 02 WEANED OFF DUE TO PT'S DISCOMFORT WITH NC- SPO2 HAVE MAINTAINED > THAN 65% ON RA. PT HAS NO C/0 OF DYSPNEA OR SOB. RR 18-25, UNLABOURED AND REGULAR. BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER LOBES, CRACKLES TO THE BILATERAL BASES.\n\nGI: ABDOMEN IS FIRM AND DISTENDED, NO C/O PAIN WHEN PALPATED. NO BM THIS SHIFT. BS X 4 QUADRANTS. NO C/O N/V/D. ABLE TO TOLERATE DINNER WITHOUT DIFFICULTY.\n\nGU: VOIDS WITHOUT DIFFICULTY. CLEAR, YELLOW URINE IN ADEQUATE AMOUNTS. SCHEDULED PD. PT. ABLE TO TOLERATE PD WITH MINIMAL CRAMPING- GIVEN PERCOCET AS ORDERED AS NEEDED.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK AND BUTTOCKS.\n\nENDO: PT CONTROLLED WITH SLIDING SCALE.\n\nPLAN: CALL OUT TO TELEMETRY FLOOR. CONTINUE PD. MONITOR LYTES AND GLUCOSE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-21 00:00:00.000", "description": "Report", "row_id": 1346894, "text": "MICU NPN 0700-1900\n23 year old man with DKA, ESRD on CAPD, vomiting, diarrhea, HTN labetalol gtt weaned to off.\n\nREVIEW OF SYSTEMS:\nNEURO: alert oriented times three, OOB to commode with supervision, ambulate safely\n\nCV: HR 90-100 SR/ST, BP 130's-150's/ labetalol gtt weaned to off changed to po, cycling CK's 3rd set sent at 1600 CK's 300's, 1st trop 5.4, denies CP, po aspirin started\n\nRESP: RR 20's O2 wean to 2L n/c, O2 sat 93-985, breath sounds crackles at bases, no SOB/DOE.\n\nGU: CAPD 5x day, instill only 2Liters of 1.5% dextrose alternate with 2.5% dextrose, effluent clear light yellow, -fibrin, fluid cultured this am, first run only 500cc effluent, 2nd run 1500cc return, intern aware of retaining of fluid. C/O cramping abd discomfort with 2L dwell. Usual home treatment is 6L on cycler overnight.\n\nGI: ABD soft +BS, nausea x2 medicated with zofran, vomit x1 ~100cc bilious liquid, diarrhea x1 stool cdiff and cultures sent, NPO except meds with water, drinking ice water\n\nHEME: am hct 28, repeat hct 21, to be transfused with 1unit PRBC's\n\nENDO: FS 115-298, sliding scale humalog provided\n\nSOCIAL: lives with , no visitors today, father called and will bring in the CAPD when he visit late tonight or tomorrow.\n\nPLAN: follow ck's, transfuse 1 unit prbc's, NPO, antiemetics prn, maintain saefety.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-21 00:00:00.000", "description": "Report", "row_id": 1346895, "text": "addendum\nFather visited briefly dropping off CAPD cycyler and taking home wallet and dirty clothing\n" }, { "category": "Nursing/other", "chartdate": "2155-06-22 00:00:00.000", "description": "Report", "row_id": 1346896, "text": "NPN\nMICU\n7 PM - 7 AM\nESRD/ TYPE 1 DM / HTN\nS \" I'm so thirsty ..I just want to eat \"\no pls see careview flowsheet for all obj/numerical data\ncv tachycardic / hypertensive ..tolerating anti-hypertensives ...\nruling in by ck's/troponin ...bolused with 4000 units of heparin and gtt at 1000 u/hr...pre-heparin ekg done ...denies chest pain or heartburn ...\nresp depent cxs 1/3 up bilat ..non-prod cough ..on 2l np\ngi kept npo ..one episode of loose diarrheal stool...cramping with pd cath instillation\ngu void approx 200 cc yellow urine ...pt able to tolerate only 2L of pd cath fluid dwell..with 200 cc pd cath efluent remain instilled despite position changes ...6.5 L positive positive at midnight\nid ..all cxs pndg ..pd cath fluid clear\nendocrine finger sticks with sliding scale ...\na hemodyn stable ....brittle diabetic\np close supervision intake /output ..finger sticks ..\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-21 00:00:00.000", "description": "Report", "row_id": 1346893, "text": "NURSING ADMISSION AND PROGRESS NOTE 0400-0700\nRECEIVED PT FROM THE EW. ARRIVED VIA STRETCHER- TX TO MICU 773 WITHOUT INCIDENT. ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR FUNCTIONING PROPERLY.\n\nTHIS IS 23 Y/O M ADMITTED WITH DKA, SEVERE HTN AND DECOMPENSATED HEART FAILURE. TYPE 1 DIABETES SINCE AGE 16. CHRONIC COMPLICATIONS INCLUDING RETINOPATHY, NEUROPATHY AND ESRD. STARTED ON PERTONEAL DIALYSIS IN -3 DAYS AGO, PT N/V AND COUGH WITH BLOOD GLUCOSES > THAN 150 (WHICH IS THE HIGHEST THAT HIS GLUCOMETER READS). FATHER DROVE HIM TO THE ED ON . UPON ARRIVAL GLUCOSE WAS IN THE 400'S. HTN AT 205-140.\n\nNEURO: ALERT AND ORIENTED X 3. OBEYS COMMANDS. SPEECH IS CLEAR. MAE X 4 WITHOUT DIFFICULTY. PERRLA, 3/B. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: PT ARRIVED ON 100%NRB. WEANED TO 4L NC WITH GOOD RESULTS. BBS=, ESSENTIALLY CLEAR. BILATERAL CHEST EXPANSION NOTED. SP02 > OR = TO 93%. TACHYPNIC AT 30'S WHEN ANXIOUS BUT WILL SETTLE TO 18-25 WHEN RESTING. REGULAR AND UNLABOURED. NON-PRODUCTIVE COUGH.\n\nCV: S1 AND S2 AS PER AUSCULTATION. HYPERTENSIVE, SBP 140-170'S. BEING CONTROLLED BY LABETALOL GTT. TITRATING AS NEEDED. PALPABLE PULSES TO BILATERAL RADIALS AND DORSALIS. DENIES ANY CHEST PAIN. NO SIGNS OF JVD.\n\nGI: ABD IS DISTENDED, SOFT, BS X 4 QUADRANTS. INITIALLY C/O NAUSEA- GIVEN 4MG OF ZOFRAN WITH GOOD RESULTS. CURRENTLY IS COMFORTABLE WITH NO C/O N/V/D. PASSING FLATUS WITHOUT DIFFICULTY. PERITONEAL DIALYSIS PORT IS SECURE AND INTACT.\n\nGU: HAS NOT VOIDED SINCE ADMISSION. PT DENIES THAT HE WOULD HAVE ANY DIFFICULTY- JUST HAS NOT NEEDED TO GO- \"SOON\".\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nACCESS: 18G PIV TO RIGHT AC AND 20G PIV TO LEFT HAND.\n\nENDO: CURRENTLY BS IN THE 150 RANGE. INSULIN DRIP IS OFF. RECEIVED 7 UNITS OF REGULAR INSULIN GIVEN SUBCU.\n\nSOCIAL: FATHER IN TO VISIT- AWARE OF PT'S CONDITION.\n\nPLAN: CONTINUE TO MONITOR ENDOCRINE STATUS. BLOOD SUGARS Q 2 HOURS PLEASE. CONTINUE TO MONITOR AND CONTROL HTN WITH LABETALOL DRIP- WEAN AS TOLERATED. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-24 00:00:00.000", "description": "Report", "row_id": 1346902, "text": "MICU NPN 0700-1900\n\n23 year old man micu day 4, s/p caridac cath this am, cath reveals clean coronaries and PCWP 26.\n\nREVIEW OF SYSTEMS:\nNEURO: alert oriented times three, +MAE\nCV: HR 80-90 SR no VEA, BP 130-150/, IV NTG in cath lab, changed back to po isordil, + pedal edema, cath site right groin clean dry intact sheaths pulled at 11am, bedrest til 5pm, DP easily palpable, weak palp PT\nRESP: lungs clear O2 sat >96%\nGI: h/o gastrparesis, cont reglan 10mg IV tid with meals, NPO for breakfast, taking /cardiac diet for lunch without difficulty, no nausea, no stool.\nGU/PD: PD Q 2 while in MICU, once transfer to floor switch to PD via cycler, cycler with pt in room, dialysate to be brought in from home tonight.\nSKIN: intact\nID: afebrile, cont po levoflox Q48\nACCESS: 1 peripheral IV\n\nPLAN: stable for transfer to floor, PD to be changed to home regime, cont to follow blood sugars closely\n\n\n" }, { "category": "ECG", "chartdate": "2155-06-22 00:00:00.000", "description": "Report", "row_id": 145045, "text": "Sinus rhythm\nLong QTc interval\nLateral T wave changes are abnormal for age/sex\nAnterolateral ST-T wave abnormalities\nSince previous tracing of : heart rate decreased\n\n" }, { "category": "ECG", "chartdate": "2155-06-21 00:00:00.000", "description": "Report", "row_id": 145046, "text": "Sinus tachycardia\nLeft atrial abnormality, increased voltage\nST junctional depression is nonspecific\nRepolarization changes may be partly due to rate\nSince previous tracing of : increased heart rate\n\n" }, { "category": "ECG", "chartdate": "2155-06-25 00:00:00.000", "description": "Report", "row_id": 145044, "text": "Sinus rhythm, rate 89. Left ventricular hypertrophy. Lateral repolarization\nchanges consistent with left ventricular hypertrophy. Q-T interval\nprolongation. Compared to the previous tracing of there is an overall\nincrease in QRS voltage, but compared to the previous tracing of \nprecordial QRS voltage is less. Non-specific repolarization abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2155-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1260290, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB W/LOW O2 SAT\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and hypoxia.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of . The\n cardiac silhouette is prominent. There is interval worsening of aeration\n diffusely, right greater than left. There is diffuse increase in interstitial\n markings, with scattered small areas of air space infiltrate on the right. The\n lateral costophrenic angles are sharp, without effusion. The osseous\n structures are unremarkable.\n\n IMPRESSION: Worsened aeration, as described. Findings are nonspecific amd\n could reflect pulmonary edema vs. an infectious/inflammatory process, among\n other etiologies.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2108-02-10 00:00:00.000", "description": "Report", "row_id": 1581120, "text": "NPN\n\nNeuro: Pt alert, oriented, c/o feeling tired, with encouragement he did get OOB to wash with the help of his wife.\n\nCV: VSS SBP 106-140s/60s-90s, HR low 100s\n\nResp: He conts with his riboviron treatments q8 hrs, LS clear though he conts to have a dry cough which seem to coinside with his treatments. A sputum was sent, results are pending, he had a CXR on the which is clear per report.\n\nGI: He conts to have short periods of n/v, he said that they are mainly started with the coughing which causes him to vomit. He was given phenergan which helped mainly by putting him to sleep, zofran seemed to work fairly well, the n/v decreased and he was able to take his pills though he did not eat any of his meals. He conts to have diarrhea, he said that he had this prior to being admitted for his RSV. ABD is soft, nontender.\n\nGU: Voiding into a urinal, fair u/o\n\nID: Spiked to 101.8, pan cultured - blood, urine, sputum, stool, he went down for a CXR. ID as well as the transplant team were contact. antibiotics were started.\n\nCyclosporine: His level was 415 - his dose will be decreased to 75 .\n\nSoc: His wife and mother were both here most of the day, his brothers came up as well. He seems in fair spirits though tired and frustrated with the length of time here.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2108-02-10 00:00:00.000", "description": "Report", "row_id": 1581121, "text": "RESP CARE\nPT GIVEN 2MG IN 33 ML STERILE H2O VIA SPAG AT 0845 AND 1600 PT. SOMETIMES VOMITS DUE TO COUGHING FITS. NO OTHER INCIDENT.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-11 00:00:00.000", "description": "Report", "row_id": 1581122, "text": "Respiratory Care\nPt received from 12am to 2am, tol. well with no problems. Next rx scheduled 8am.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-11 00:00:00.000", "description": "Report", "row_id": 1581123, "text": "NPN 1900-0700\n\nNeuro: A&O X3, pleasant, cooperative. Slept well during the night in between interventions. No anxiety exhibited. OOB X1 to wash up after ribavirin treatment. Steady on feet but weak.\nCV: NBP 110-112/74-76; HR 70's, regular. Tmax 98po. No peripheral edema, good peripheral pulses. Is receiving TPN as ordeed.\nResp: Ribavirin treatment given at 4am; 2 more treatments planned today at 10a and 4p then to be discontinued. Pt tolerated treatment well tonight. Occasional nonproductive cough. Lungs are CTA.\nGI: Some nausea at beginning of shift in the evening but this subsided after pt given zofran 4mg IVP. No vomiting, ate very little dinner. Abdomen is soft, ND, +BS.\nGU: Voiding in urinal; urine is dark amber. Pt aware that he should drink more liquids. D51/2NS infusing intermittnetly while TPN is not running.\nID: Cyclosporin given last night at 2200; Cefapime started at 8p. Pt unable to take po acyclovir at scheduled time due to nausea but finally taken around 2300. Diffuse erythematous rash continues.\nA/P: RSV pnx/complete ribavirin treatments today at 4p as scheduled using all precautions; administer other abx as ordered. Monitor temp, WBC's. Monitor cyclosporin level daily at 10am.\nA/P: ALL/ monitor WBC's and other labs.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-11 00:00:00.000", "description": "Report", "row_id": 1581124, "text": "Resp. Care\nPatient given x 2 ribivarin tx's as ordered tolerating well. Regimen finished.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-09 00:00:00.000", "description": "Report", "row_id": 1581116, "text": "NPN (NOC): PT HAD HIS UPS AND DOWNS LAST NOC. EARLIER IN SHIFT HAD INTERMITTANT CRAMPING PAIN IN HIS HANDS NOT RELEIVED BY HEAT/COLD OR MASSAGE. FENTYNL 25 MCG'S IV GIVEN W/ RELIEF, BUT CRAMPING WAS SUBSIDING BEFORE DRUG GIVEN. VALIUM 5 MG'S PO GIVEN AT HS AND PT HAS NOT HAD CRAMPING SINCE. MG 2AMPS + KCL 40 MEQ'S GIVEN, AM LABS PND. ONE LITER D51/2 BEGUN TO RUN AT 100 CC'S/HR TO SUPPLEMENT PO INTAKE. TPN UP AT 2AM TO RUN OVER 12 HRS. UO 1400 CC'S OVERNOC. RIBAVIRAN RX GIVEN OVER 2 HRS W/O INCIDENT. AFBRILE. RR NONLABORED, LUNGS CLEAR BUT HE HAS SNIFFLES.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-09 00:00:00.000", "description": "Report", "row_id": 1581117, "text": "MICU/SICU NPN Day #4\nEvents: Ribavirin rx complete, increased coughing today causing nausea.\n\nS: \"It's so dry in here.\"\n\nO:\n\nNeuro: A&Ox3, denies pain, MAEW, ambulatory, better control of hand cramping today\n\nResp: SpO2 98-100% on RA, LS CTA, Ribavirin TID\n\nCV: , see flowsheet for data\n\nGI/GU: abd soft, NT/ND, BS present, poor appetitie, nausea this PM well relieved with promethazine, voiding qs in urinal\n\nLines: right SC DL Hickmann\n\nSocial: multiple famly members in to visit today\n\nA:\n\nhigh risk for infection r/t HSCT\nrisk for fluid volume deficit\n\n\nP:\n\ncontinue Ribavirin rx to 15/15, encourage aggressive pulmonary toilet, push PO fluids, follow I/O & lytes closely and replete, continue TPN\n" }, { "category": "Nursing/other", "chartdate": "2108-02-10 00:00:00.000", "description": "Report", "row_id": 1581118, "text": "Pt stable throughout the night. Tolerated cephelasporin IVPB infused from 2200 to 0000 in designated Hickman line for cephelasporin only; level due to be drawn exactly at 1000 as per Oncology. AM labs to be drawn as well at 10AM by peripheral route. VSS. Pt c/o headache at 12AM relieved w/ tylenol 650mg PO. Pt slept comfortably throughout the night. When awake, pt anxious, refused meds and bath. Lorazepam given for anxiety, emotional support. Occasional cough, yellow productive at times. Ribavirin given by RT as per protocol; TPN held during treatment.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-10 00:00:00.000", "description": "Report", "row_id": 1581119, "text": "pt recieved Ribavirin tx during PM without incidence. cleanable equipment was removed for sterilization.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-07 00:00:00.000", "description": "Report", "row_id": 1581112, "text": "D: Please see MD notes/orders. Neuro: Pt A&O. CV: Not on telemetry, apical pulse with rrr, sbp 90's-120s. Pulm: 02 sat 97% on room air, lungs clear bilaterally. Pt with non productive dry cough, rhinorrhea. States \"runny nose\" essentially unchanged, nose drains clear sputum frequently. GU: voids 300+cc clear amber urine q 3-4hrs. GI: Abd soft, bs+, appetite poor. Skin: surfaces intact, peripheral pulses +. Pt has GVHD resulting in flaking,brown skin on head/back. Soc: Wife, mother and several brothers are staying in while pt being treated. Pt/wife have small children in being cared for by family members. P: Pre medicated with ativan prn before ribavarin treatments. Have pt wash all exposed body surfaces after each treatment. Maintain neutropenic precautions and continue Cyclosporin/other meds for GBVH. Transfuse as ordered for hct 26.5, premedicate prn. Encourage po intake (BMT/low bacteria trays), initiate tpn as ordered. Keep family/pt up to date on plan of care. R: 1600 dose ribavarin comeplete, wife in, assisting pt with bath. Tylenol/bendadryl given per med sheet pre transfusion. All else as above, full report given to oncoming shift.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-08 00:00:00.000", "description": "Report", "row_id": 1581113, "text": " 1900 to 0700\nNeuro: Pt A&O x3. Received 0.5mg Lorazepam just prior to his Ribavirin treatment and tolerated it well.\n\nCV: VSS. Pt is not on a cardiac monitor.\n\nResp: Pt has non productive cough. Ribavirin treatments going well.\n\nGU/GI: Pt voiding amber colored urine in urinal. Incouraged to drink his bottled water at the bed side as his wife reports he easily becomes dehydrated.\n\nSocial: Wife, brother and mother visited this evening. Wife spent the night in the lounge to be near if we needed her. Pt had a good night and slept inbetween disturbances. Assisted with his bath to wash off the Ribavirin residue as pt dislikes using the shower in his room.\n\nPlan: Continue treatments MD order until Saturday. Provide support to wife and family.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-08 00:00:00.000", "description": "Report", "row_id": 1581114, "text": "MICU/SICU NPN Day #3\nEvents: Ribavirin treatments x2, increased cramping in hands\n\nS: \"I wish I could get some fresh air\"\n\nO:\n\nNeuro: pt is A&Ox3, MAEW, ambulating unassisted, reports severe cramping in bilateral hands, some relief after Mg2+ repletion\n\nResp: SpO2 97% on RA, LS CTA, intermitted nasal/sinus congestion\n\nCV: , pt is off bedside monitor\n\nSkin: skin sloughing from face, back and trunk secondary to GVHD\n\nGI/GU: abd soft, ND/ND, BS present, poor appetite, voiding qs in urinal\n\nFEN: TPN infusing as ordered, push fluids, Mg2+ repleted\n\nLines: right SC DL Hickmann with dedicated CSA port\n\nA:\n\nimpaired skin r/t inflammatory response\nrisk for fluid volume defecit r/t poor PO intake, poor appetite\npain r/t cramping of hands\n\nP:\n\ncontinue Ribavirin for total 15 rx, push PO fluids, consider IV hydration to aid cramping while PO intake poor, aggressive pulmonary toilet\n" }, { "category": "Nursing/other", "chartdate": "2108-02-09 00:00:00.000", "description": "Report", "row_id": 1581115, "text": "Respiratory Care:\n\nRibaviron given with spag unit and tent at 12:10am. 2gm Ribaviron in 33ml of sterile water. Rx stopped at 2:10 am. Tolerated well. Plan: Will continue to follow with Ribaviron Tid.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-07 00:00:00.000", "description": "Report", "row_id": 1581110, "text": "Respiratory Care\nPt was started on Ribaviron therapy, first dose started at 12am, stopped at 2am. Pt tol. well; no complaints. Next dose scheduled at 8am.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-07 00:00:00.000", "description": "Report", "row_id": 1581111, "text": "S/MICU Nursing Progress Note\n Pt is a 44 y/o gentleman s/p MUD for ALL recently d/c on presented today for labs check and c/o runny nose, flu like symptoms, nasal washing was + for RSV and admitted for ribiviran. TID treatments lasting 2hr. first treatment given at 12am and tolerated well.\n Pt has a double lumen hickman in the R subclavian, with one port receiving cyclosporine, infusing via pt's pump. Level yesterday was slightly high at 730 and dose decreased by 24mg. Pt did receive IVIG on the heme/onc floor and once ribiviran done given a dose of syagis at 2am. tolerated well.\n Skin: dry flaky skin, ichy at times, reddened area around back is presently on cyclosporine and prednisone to treat GVHD.\n Resp: on RA, no c/o SOB only of his runny nose, occasionally will have productive cough.\n Cardiac: not on telemetry, HR in the 60's reg, BP 150-160/90's\n GU: voiding well using urinal.\n GI: did c/o nausea for short period before treatment was started. + stool med sized. taking po fluids.\n Plan: will continue the treatment for TID x 5days. follow cyclosporine levels and adjust according to MD orders. monitor rash\n" }, { "category": "Nursing/other", "chartdate": "2108-02-11 00:00:00.000", "description": "Report", "row_id": 1581125, "text": "NPN\n\nNeuro: Alert, oriented, OOB to commode and to wash. He is anxious to get out of his room and this unit, the treatments end this afternoon.\n\nCV: BP 116-130/70s, HR 78-120 and regular.\n\nResp: LS cracles in his L bases, 02 SAT 95-96% on RA, RR 24. He conts to have a cough, it is mainly dry. Another sputum is needed because the specimen from yesterday had >10 epi in it. He had his last ribavirin treatment today ending at 5:30 pm.\n\nGI: ABD soft, nontender, still no apptite, TPN has been infusing but rather spuratically due to the ribavirin treatments. Occationally c/o nausea and he was given Zofran 4 mg with good effect. He conts to have diarrhea which is not new for him, he was asking for lomotil but this cannot be given until his stool specs come back negative.\n\nGU: His urine conts to be dark, 400cc out today, creat is 1.0.\n\nSoc: His family has been in to visit, his brothers played cards with him this afternoon.\n\nID: Afebrile, conts on abx, he now has crackles in his LLL. His cyclosporin trough cont to be too high, he will start on an infusion after he leaves his room.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2108-02-12 00:00:00.000", "description": "Report", "row_id": 1581126, "text": "P-MICU NPN 7p-7a\nSystems Review:\n\nResp: O2 Sats on RA 96-97%, RR 18-24, non-labored. LS with rales bibasilarly.\n\nCV: VSS. BP 126/. HR 84-100 regular.\n\nGI: +BS. No stool. Requesting imodium again, not to be administered until culture results return. C/O \"heartburn\", notified HO , who went and evaluated pt. Ordered and received 30ml maalox times one with good relief. Taking in no solid po's this shift, just some po fluids. Recieving TPN when IV meds have been infused.\n\nGU: Voiding independently, dumping urine twice, informed pt to save output EACH time he voids.\n\nEndo: Recieving regular SS coverage per parameters. Documented in carevue.\n\nNeuro: Alert and oriented, pleasant and cooperative. At times he does seem a little forgetful, requesting things multiple times (eg. requesting a bedside table, or not following instructions after multiple requests.\n\nSocial: Family, wife and brothers, were in until ~11am. Will be back in the am.\n\nID: Afebrile, receiving IV abx per orders.\n" }, { "category": "Nursing/other", "chartdate": "2108-02-12 00:00:00.000", "description": "Report", "row_id": 1581127, "text": "NPN\n\nNeuro: Alert, oriented.\n\nCV: VSS, his HR does increase with activity to the 120s, it decreases to the 80s after resting.\n\nResp: LS crackles in the LLL, he had a chest CT which per report is negative. 02 SAT is in the mid to upper 90s, he cont to have a cough though fairly nonproductive, a sputum was sent for culture. He has been afebrile, he conts on abx. He was given an incentive spirometer to use but he has not done so. His WBC is 3.3 no bands.\n\nGI: He conts to have a poor appitite, TPN is being given over 12 hrs. He has had frequent stooling, a spec was sent for a viral clx.\n\nGU: Fair u/o.\n\nSoc: His family has been in most of the day, he tried to sleep but was not successful. OOB to the chair and commode.\n" }, { "category": "Radiology", "chartdate": "2108-02-06 00:00:00.000", "description": "P CHEST (PA & LAT) PORT", "row_id": 818366, "text": " 7:59 PM\n CHEST (PA & LAT) PORT Clip # \n Reason: 44 year old male with ALL s/p BMT to start ribivarin therapy\n Admitting Diagnosis: RSV PNUEMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with ALL day 33 s/p BMT please evaluate for any pathology.\n Came in with Upper respiratory tract infection and RSV + swab.\n REASON FOR THIS EXAMINATION:\n 44 year old male with ALL s/p BMT to start ribivarin therapy. Please evaluate\n for any pathology.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bone marrow transplant, RFB infection.\n\n AP CHEST: Compared with , there is no significant change in the\n appearance of the heart or lungs. The right central venous catheter remains\n in satisfactory position and there has been interval removal of the left\n central line. No focal consolidations, pleural effusions, vascular\n congestion, or pneumothorax.\n\n IMPRESSION:\n\n No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-02-12 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 818934, "text": " 11:30 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? RSV/lower tract disease\n Admitting Diagnosis: RSV PNUEMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p BMT for ALL admitted with RSV +, now completed ribavirin\n treatment\n REASON FOR THIS EXAMINATION:\n ? RSV/lower tract disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 44 y/o male status post bone marrow transplant with RSV\n infection, status post treatment.\n\n CT CHEST WITHOUT CONTRAST: Comparison is made to previous films from .\n\n TECHNIQUE: Helically acquired contiguous axial images of the chest were\n obtained without IV contrast.\n\n FINDINGS: Previously described mediastinal lymphadenopathy is now resolved.\n There is no hilar or axillary lymphadenopathy. There is a very small area of\n ground glass opacity in the superior right middle lobe (series 2, images\n 30-31). This is of doubtful clinical significance. There is also a small\n peripheral opacity in the left lower lobe, consistent with atelectasis. There\n are no areas of consolidation. The previously described bilateral pleural\n effusions are resolved. The heart, pericardium and great vessels are\n unremarkable.\n\n The visualized portions of the liver, spleen, pancreas, adrenal glands and\n kidneys are unremarkable. There is no free intra-abdominal fluid. The\n visualized osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Interval resolution of mediastinal lymphadenopathy.\n 2. Interval resolution of bilateral pleural effusions.\n 3. No evidence of pneumonia.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2108-02-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 818801, "text": " 2:49 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infiltrate. (Note: pt is in a gown b/c he is g\n Admitting Diagnosis: RSV PNUEMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45M with leukemia. S/p transplant. With acute fever and cough.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate. (Note: pt is in a gown b/c he is getting ribavirin\n therapy)\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Acute fever and cough. Leukemia.\n\n Comparison is made to previous study of .\n\n A right internal jugular vascular catheter remains in place, terminating in\n the region of the proximal right atrium. The cardiac and mediastinal contours\n are normal. The lungs appear grossly clear, and no pleural effusions are\n identified. Skeletal structures reveal mild curvature of the spine.\n\n IMPRESSION:\n\n No radiographic evidence of pneumonia.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2154-04-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1239632, "text": " 9:52 AM\n CHEST (PA & LAT) Clip # \n Reason: (L) PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\RIGHT AND LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with s/p CABg x4\n REASON FOR THIS EXAMINATION:\n (L) PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man status post CABG, complicated with small\n pneumothorax.\n\n COMPARISONS: -- .\n\n FINDINGS: A tiny left apical pneumothorax remains. Small bilateral pleural\n effusions are again seen. The heart remains enlarged. The lungs are\n otherwise clear. There is no new consolidation. Median sternotomy wires are\n intact. Left basilar atelectasis is unchanged.\n\n IMPRESSION:\n 1. Stable small left apical pneumothorax.\n 2. Stable cardiomegaly and left basilar atelectasis and small effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1239548, "text": " 3:14 PM\n CHEST (PA & LAT) Clip # \n Reason: please obtain CXR at 1500\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\RIGHT AND LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with removal of chest tubes\n REASON FOR THIS EXAMINATION:\n please obtain CXR at 1500\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, on .\n\n COMPARISON: Comparison x-ray of .\n\n FINDINGS: Following removal of left-sided chest tube, a small left apical\n pneumothorax has developed. This finding has been communicated by telephone\n to at 4:10 p.m. on , at the time of discovery.\n Stable postoperative widening of the cardiomediastinal contours. Patchy and\n linear atelectases are present in the left perihilar and basilar regions as\n well as small left pleural effusion.\n\n IMPRESSION:\n 1. Small left apical pneumothorax following chest tube removal. Please see\n above for documentation of critical results.\n 2. Stable postoperative widening of cardiomediastinal contours.\n 3. Left basilar atelectasis and small effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-16 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1238845, "text": " 7:35 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Please eval for carotid stenosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CAD\n REASON FOR THIS EXAMINATION:\n Please eval for carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n \n Depart of Radiology\n Standard Report - Carotid Study\n\n\n Study: Carotid Series Complete\n\n Reason: .54 year old man with CAD.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is no plaque seen in the ICA . On the left there is mild\n heterogeneous plaque seen in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 65/21, 68/24, 76/29, cm/sec. CCA peak systolic\n velocity is 106 cm/sec. ECA peak systolic velocity is 148 cm/sec. The ICA/CCA\n ratio is .71 These findings are consistent with no stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 65/26, 77/35, 54/24, cm/sec. CCA peak systolic\n velocity is 109 cm/sec. ECA peak systolic velocity is 163 cm/sec. The ICA/CCA\n ratio is .70. These findings are consistent <40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA no stenosis.\n Left ICA <40% stenosis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1239248, "text": " 4:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\RIGHT AND LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CAD s/p CABG. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post CABG.\n\n Comparison is made with preop evaluation of .\n\n There are low lung volumes. Swan-Ganz catheter tip is coiled in the left main\n pulmonary artery. The tip comes back to the main pulmonary artery facing the\n right pulmonary artery. ET tube is in standard position and the tube tip is\n in the stomach. Mediastinal left chest tubes are in place. There is no\n pneumothorax. If any there are small bilateral pleural effusions. There is\n mild atelectasis in the left lower lobe. There is postoperative mediastinal\n widening. The cardiac size is top normal.\n\n was paged at 4:45 p.m. on .\n\n" }, { "category": "Echo", "chartdate": "2154-04-18 00:00:00.000", "description": "Report", "row_id": 104445, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG\nStatus: Inpatient\nDate/Time: at 12:20\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. Good (>20 cm/s) LAA ejection velocity.\nNo thrombus in the LAA.\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 LV wall thickness. Normal LV cavity size. Low normal\nLVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter. No\natheroma in descending aorta. No thoracic aortic dissection.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. of the mitral chordae (normal\nvariant). No resting LVOT gradient. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\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. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPRE-CPB:\nThe left atrium is moderately dilated. No thrombus is seen in the left atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler.\n\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is low normal (LVEF\n50-55%). Right ventricular chamber size and free wall motion are normal.\n\nNo thoracic aortic dissection is seen. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis. Trace\naortic regurgitation is seen.\n\nThe mitral valve leaflets are structurally normal. Mild to moderate (+)\nmitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen.\n\nDr. was notified in person of the results at time of study.\n\nPOST-CPB:\nThe left ventricular systolic function remains normal, estimated EF=55%. Right\nventricular function remains normal.\n\nThe mitral regurgitation is now trace. The TR is now mild. Other valvular\nfunction remains unchanged.\n\nThere is no evidence of aortic dissection.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-17 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1238997, "text": " 9:46 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\\RIGHT AND LEFT HEART CATHETERIZATION\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\RIGHT AND LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with multivessel CAD - preop CABG\n REASON FOR THIS EXAMINATION:\n r/o cardiopulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with multivessel coronary artery disease, pre-op\n CABG.\n\n COMPARISONS: None.\n\n FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax.\n The cardiomediastinal silhouette is normal. There is no evidence of pulmonary\n edema. There are no acute skeletal abnormalities.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "ECG", "chartdate": "2154-04-18 00:00:00.000", "description": "Report", "row_id": 306650, "text": "Sinus rhythm. Prominent Q wave in lead V1 of unknown significance. There is\nlow limb lead voltage and non-specific ST-T wave changes with a diminished\nvoltage as compared with previous tracing of . Otherwise, no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2154-04-16 00:00:00.000", "description": "Report", "row_id": 306651, "text": "Sinus rhythm. Non-specific inferior ST-T wave changes. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2172-03-11 00:00:00.000", "description": "Report", "row_id": 68356, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 71\nWeight (lb): 192\nBSA (m2): 2.07 m2\nBP (mm Hg): 130/79\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 09:38\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: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity.\nModerate-severe regional left ventricular systolic dysfunction. Moderately\ndepressed LVEF. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal\n- hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid inferior -\nakinetic; basal inferolateral - hypo; mid inferolateral - akinetic; basal\nanterolateral - hypo; mid anterolateral - hypo; inferior apex - akinetic;\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: Normal mitral valve leaflets. Mild thickening of mitral valve\nchordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is moderately dilated. There is moderate to severe regional\nleft ventricular systolic dysfunction with akinesis of the inferior wall and\nhypokinesis of the basal to mid septum and inferolateral walls. Overall left\nventricular systolic function is moderately depressed (LVEF= 30-35 %). Tissue\nDoppler imaging suggests a normal left ventricular filling pressure\n(PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. The mitral valve leaflets are structurally\nnormal. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the regional\nwall motion abnormality is worse in the anteroseptum.\n\n\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370449, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented to the ED with dizziness,HCt 19,as per the pt he had\n black dark stool in the am,no bm in after coming in the icu.\n Action:\n Received 4u PRBC,received protonix bolus and on protonix drip,contd\n home meds\n Response:\n Rpt hct 25.8 after 4u prbc\n Plan:\n Goal hct >30,check hct q6h(next 1030 am)cont IV PPI,?plan for endoscopy\n in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt known CAD,s/p triple bypass,presented with STT changes,rpt Troponin\n 1.17,denied any chest pain/sob,received aspirin in the ED\n Action:\n Cycled cardiac enzymes,contd tele monitoring,received lasix 10 mg IV\n Response:\n Sbp 90-120,hr 80,does goes to 110\ns with exertion,rpt cardiac enzymes\n at 0400am shows worsening with troponin 2.40\n Plan:\n Will start lopressor once BP stable\n Hyperglycemia\n Assessment:\n Known IDDM,pt didn\nt take insulin last day,presented with a blood sugar\n of ~700,received 10 U reg insulin IV in the ED,rpt FS in the 489 in\n the ED,pt was 440 at the time of presentation in the micu\n Action:\n Received 20 u reg insulin sc(10+10),monitored fs q2-3 hrly.\n Response:\n 0400am fs 199.\n Plan:\n Cont to follow aggressive sliding scale.\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370461, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Events- Transfused 2u prbc and 1 u ffp.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370452, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented to the ED with dizziness,HCt 19,as per the pt he had\n black dark stool in the am,no bm in after coming in the icu.\n Action:\n Received 4u PRBC,received protonix bolus and on protonix drip,contd\n home meds\n Response:\n Rpt hct 25.8 after 4u prbc\n Plan:\n Goal hct >30,check hct q6h(next 1030 am)cont IV PPI,?plan for endoscopy\n in am.plan to give 2 more unit of prbc\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt known CAD,s/p triple bypass,presented with STT changes,rpt Troponin\n 1.17,denied any chest pain/sob,received aspirin in the ED\n Action:\n Cycled cardiac enzymes,contd tele monitoring,received lasix 10 mg IV\n Response:\n Sbp 90-120,hr 80,does goes to 110\ns with exertion,rpt cardiac enzymes\n at 0400am shows worsening with troponin 2.40\n Plan:\n Will start lopressor once BP stable\n Hyperglycemia\n Assessment:\n Known IDDM,pt didn\nt take insulin last day,presented with a blood sugar\n of ~700,received 10 U reg insulin IV in the ED,rpt FS in the 489 in\n the ED,pt was 440 at the time of presentation in the micu\n Action:\n Received 20 u reg insulin sc(10+10),monitored fs q2-3 hrly.\n Response:\n 0400am fs 199.\n Plan:\n Cont to follow aggressive sliding scale.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370527, "text": "60 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented with a hct 19,received &U prbc since admission,rpt hct\n 27.7 last pm.no c/o dizziness\n Action:\n Received 1 U Prbc in this shift,followed hct q6h\n Response:\n Rpt hct 32.\n Plan:\n Goal Hct >30,plan for EGD if ekg without changes\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for MI,no c/o chest pain,sinus rythum with pvc\n Action:\n Cycled cardiac enzymes,tele monitoring,contd metoprolol,received Lasix\n 20 mg iv\n Response:\n Sats mid 90\ns,hr 70\ns,sbp 100-130,trop trending down.\n Plan:\n Follow cardiac enzymes,need echocardiogram.\n" }, { "category": "Physician ", "chartdate": "2172-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370536, "text": "Chief Complaint: GI bleed, NSTEMI\n 24 Hour Events:\n Cards- TTE to assess regional WMA, hold ASA per attdg for now, GI\n aggres, daily ECG, transfuse HCT 30 with lasix\n GI- hold on EGD until hct stable and cardiac issues stable\n transfused 1 unit for hct 27, lasix 20mg IV given\n startes metoprolol \n 11PM HCT 32\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:18 PM\n Pantoprazole (Protonix) - 12:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea\n Respiratory: No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 81 (70 - 94) bpm\n BP: 127/63(78) {105/51(63) - 137/85(96)} mmHg\n RR: 8 (8 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,593 mL\n 10 mL\n PO:\n TF:\n IVF:\n 125 mL\n 10 mL\n Blood products:\n 2,468 mL\n Total out:\n 4,675 mL\n 800 mL\n Urine:\n 4,675 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,082 mL\n -790 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 139 K/uL\n 11.2 g/dL\n 134 mg/dL\n 2.4 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.0 %\n 4.1 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n 10:51 AM\n 05:03 PM\n 10:50 PM\n 04:09 AM\n WBC\n 5.0\n 4.9\n 4.3\n 4.1\n Hct\n 19.5\n 25.8\n 28.2\n 27.7\n 31.6\n 32.0\n Plt\n 133\n 125\n 123\n 139\n Cr\n 2.6\n 2.7\n 2.4\n TropT\n 1.17\n 2.40\n 2.55\n 2.40\n 1.71\n Glucose\n 286\n 166\n 134\n Other labs: PT / PTT / INR:14.2/25.5/1.2, CK / CKMB /\n Troponin-T:133/11/1.71, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n LDH:228 IU/L, Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:16 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": "2172-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370537, "text": "Chief Complaint: GI bleed, NSTEMI\n 24 Hour Events:\n Cards- TTE to assess regional WMA, hold ASA per attdg for now, GI\n aggres, daily ECG, transfuse HCT 30 with lasix\n GI- hold on EGD until hct stable and cardiac issues stable\n transfused 1 unit for hct 27, lasix 20mg IV given\n startes metoprolol \n 11PM HCT 32\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:18 PM\n Pantoprazole (Protonix) - 12:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea\n Respiratory: No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 81 (70 - 94) bpm\n BP: 127/63(78) {105/51(63) - 137/85(96)} mmHg\n RR: 8 (8 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,593 mL\n 10 mL\n PO:\n TF:\n IVF:\n 125 mL\n 10 mL\n Blood products:\n 2,468 mL\n Total out:\n 4,675 mL\n 800 mL\n Urine:\n 4,675 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,082 mL\n -790 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 139 K/uL\n 11.2 g/dL\n 134 mg/dL\n 2.4 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.0 %\n 4.1 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n 10:51 AM\n 05:03 PM\n 10:50 PM\n 04:09 AM\n WBC\n 5.0\n 4.9\n 4.3\n 4.1\n Hct\n 19.5\n 25.8\n 28.2\n 27.7\n 31.6\n 32.0\n Plt\n 133\n 125\n 123\n 139\n Cr\n 2.6\n 2.7\n 2.4\n TropT\n 1.17\n 2.40\n 2.55\n 2.40\n 1.71\n Glucose\n 286\n 166\n 134\n Other labs: PT / PTT / INR:14.2/25.5/1.2, CK / CKMB /\n Troponin-T:133/11/1.71, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n LDH:228 IU/L, Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n 60M with PMH of IDDM, CAD s/p 3 CABG, gastritis and new\n pancreatic who presents with GIB, anemia, and NSTEMI\n .\n Acute Blood Loss Anemia/GIB\n Hemodynamically stable. Guaic + stool\n makes GIB most likely. be gastritis vs. related to pancreatic\n mass. Recent colonoscopy unremarkable. No abd pain to suggest\n intra-abdominal hemorrhage. s/p 7 units prbcs and 1 unit platelets.\n Gastritis and duodenitis on EGD . Hct now stable\n - IV PPI \n - NPO for now\n - IVF\n - Active T/S, transfuse for hct<30\n - HCT q6-8h\n - Appreciate GI recs -> will scope once cards issue stable\n .\n NSTEMI/CAD\n Trop peak at 2.7. EKG with lateral ST depressions. Ces\n now trending down. Has remained asymptomatic. Likely demand related.\n - Cont to trend CEs\n - Daily EKG\n - Appreciate Cards input: will hold ASA for now\n - Restarted BB\n - Cont statin, hold ACE-I for now until GIB stable\n - TTE to assess cardiac function\n .\n Pancreatic Mass - concerning for malignancy. s/p biopy of umbilical\n nodule\n - f/u path\n - discuss with GI\n .\n Congestive Heart Failure\n EF 35% by recent echo. Clinically euvolemic\n and well compensated. Likely related to ischemic CMO.\n - Give lasix with each unit prbcs\n - Resumed BB\n - Restart ACE-I ASAP\n - Cont statin\n - Check TTE this admission\n .\n CKD: Stable. Cont to follow\n .\n Diabetes: Cont HISS with\n dose NPH at 10 units until resumes Pos\n .\n Hypertension\n Restart BB, hold ACE-I\n .\n Hyperlipidemia - Continue statin and niacin\n .\n FEN: NPO for now, replete electrolytes, regular diabetic diet\n - IVF\n .\n Prophylaxis: Pneumoboots, PPI, Bowel Regiman\n .\n Access: peripherals\n .\n Code: Full Code\n .\n Communication: Patient\n .\n Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370528, "text": "60 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented with a hct 19,received &U prbc since admission,rpt hct\n 27.7 last pm. c/o dizziness in am after getting up,?orthostatic\n Action:\n Received 1 U Prbc in this shift,followed hct q6hly\n Response:\n Rpt hct 32.\n Plan:\n Goal Hct >30,EGD as per GI reccs\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for MI,no c/o chest pain,sinus rythum with pvc\n Action:\n Cycled cardiac enzymes,tele monitoring,contd metoprolol,received Lasix\n 20 mg iv\n Response:\n Sats mid 90\ns,hr 70\ns,sbp 100-130,trop trending down.\n Plan:\n Follow cardiac enzymes,need echocardiogram.\n" }, { "category": "Physician ", "chartdate": "2172-03-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370422, "text": "Chief Complaint: Dizzy\n HPI:\n 60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n giving the patient and aspiring, which was done. In addition, the\n patient received 2L NS. CXR showed no acute cardiopulmonary process.\n EKG showed T wave inversions in inferior leads, ST elevation in , \n depression in V5 and V6.\n .\n On arrival to the ICU, vitals 98.5 102 101/55 12 95% on 2L. Pt had no\n complaints. ROS as below. Pt received additional 10 units of insulin\n for persistently elevated blood glucose.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pancreatic Tumor with Abdominal Lymphadenopathy\n Anemia\n Insulin-Dependent Diabetes Mellitus\n Chronic Renal Insufficiency\n Bilateral Hernia Repair age 5\n Congestive Heart Failure\n Coronary artery disease s/p 3-vessel CABG\n Hypertension\n Hyperlipidemia\n Atrial Septal Defect Repair\n Exposure in \n Diabetic Retinopathy\n His father died at the age of 84 from liver\n cancer, had HTN. Mother is in her 80s and alive, had breast ca. He has\n one brother who has asthma, his children are healthy.\n Occupation: IT for \n Drugs: No\n Tobacco: None\n Alcohol: Social 1-2 drinks, 2x week\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, Emesis, No(t) Diarrhea,\n Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Flowsheet Data as of 10:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 92 (92 - 102) bpm\n BP: 102/51(62) {101/51(62) - 102/55(65)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,736 mL\n PO:\n TF:\n IVF:\n 6 mL\n Blood products:\n 130 mL\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,186 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: abdominal LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, shptty, but palpable\n abdominal LAD\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CT Abd - - 1. 4.5-cm spiculated mass centered in the\n distal pancreas, highly concerning for malignancy. Mesenteric nodule\n and umbilical nodules are compatible with metastatic foci.\n 2. Splenomegaly.\n 3. Cholelithiasis, no evidence of acute cholecystitis.\n 4. Limited assessment of solid organs due to lack of IV contrast.\n .\n CXR - - No acute cardiopulmonary process.\n .\n ECG: Regular rate and rhythm, Q waves in II with questionable ST\n segment elevations. New T wave inversion in II, ST segment depression\n in V5 and V6.\n Assessment and Plan\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n 60M with PMH of IDDM, CAD s/p 3 Cabg and new pancreatic mass\n and abdominal lymphadenopathy concerning for metastatic presenting with\n symptomatic anemia.\n .\n Anemia - Anemia malignancy v GI bleed. HCT 25 last week, guaiac\n positive stools in ED. History of coffee ground emesis on capsule\n study. Gastritis and duodenitis on EGD .\n - continue PPI \n - NPO for now\n - transfuse 3 units pRBCs\n - HCT q6h\n - consider GI consult for evaluation of GI bleeding and pancreatic mass\n .\n Pancreatic Mass - concerning for malignancy. s/p biopy of umbilical\n nodule\n - f/u path\n - discuss with GI\n .\n Elevated Troponin - Discussed with cards, likely demand ischemia in\n setting of anemia v acute MI. would be difficult to heparinize in\n setting of GI bleed. conservative management for now while\n transfusing. got ASA in ED.\n - transfuse for HCT >30 given evidence of ischemia on EKG\n - cycle enzymes\n - repeat EKG\n - continue asa and statin\n .\n Hyperglycemia/IDDM - Pt did not take insulin this am.\n - Regular isnulin sliging scale\n .\n Hypertension - Hold BBlocker for now\n .\n Hyperlipidemia - Continue statin and niacin\n .\n # FEN: NPO for now, replete electrolytes, regular diabetic diet\n .\n # Prophylaxis: Pneumoboots, PPI, Bowel Regiman\n .\n # Access: peripherals\n .\n # Code: Full Code\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\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": "2172-03-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370427, "text": "Chief Complaint: Dizzy\n HPI:\n 60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n giving the patient and aspiring, which was done. In addition, the\n patient received 2L NS. CXR showed no acute cardiopulmonary process.\n EKG showed T wave inversions in inferior leads, ST elevation in , \n depression in V5 and V6.\n .\n On arrival to the ICU, vitals 98.5 102 101/55 12 95% on 2L. Pt had no\n complaints. ROS as below. Pt received additional 10 units of insulin\n for persistently elevated blood glucose.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pancreatic Tumor with Abdominal Lymphadenopathy\n Anemia\n Insulin-Dependent Diabetes Mellitus\n Chronic Renal Insufficiency\n Bilateral Hernia Repair age 5\n Congestive Heart Failure\n Coronary artery disease s/p 3-vessel CABG\n Hypertension\n Hyperlipidemia\n Atrial Septal Defect Repair\n Exposure in \n Diabetic Retinopathy\n His father died at the age of 84 from liver\n cancer, had HTN. Mother is in her 80s and alive, had breast ca. He has\n one brother who has asthma, his children are healthy.\n Occupation: IT for \n Drugs: No\n Tobacco: None\n Alcohol: Social 1-2 drinks, 2x week\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, Emesis, No(t) Diarrhea,\n Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Flowsheet Data as of 10:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 92 (92 - 102) bpm\n BP: 102/51(62) {101/51(62) - 102/55(65)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,736 mL\n PO:\n TF:\n IVF:\n 6 mL\n Blood products:\n 130 mL\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,186 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: abdominal LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, shptty, but palpable\n abdominal LAD\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CT Abd - - 1. 4.5-cm spiculated mass centered in the\n distal pancreas, highly concerning for malignancy. Mesenteric nodule\n and umbilical nodules are compatible with metastatic foci.\n 2. Splenomegaly.\n 3. Cholelithiasis, no evidence of acute cholecystitis.\n 4. Limited assessment of solid organs due to lack of IV contrast.\n .\n CXR - - No acute cardiopulmonary process.\n .\n ECG: Regular rate and rhythm, Q waves in II with questionable ST\n segment elevations. New T wave inversion in II, ST segment depression\n in V5 and V6.\n Assessment and Plan\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n 60M with PMH of IDDM, CAD s/p 3 Cabg and new pancreatic mass\n and abdominal lymphadenopathy concerning for metastatic presenting with\n symptomatic anemia.\n .\n Anemia - Anemia malignancy v GI bleed. HCT 25 last week, guaiac\n positive stools in ED. History of coffee ground emesis on capsule\n study. Gastritis and duodenitis on EGD .\n - IV PPI gtt\n - NPO for now\n - transfuse 3 units pRBCs, goal HCT >30\n - HCT q6h\n - consider GI consult for evaluation of GI bleeding and pancreatic mass\n likely EGD in am\n .\n Pancreatic Mass - concerning for malignancy. s/p biopy of umbilical\n nodule\n - f/u path\n - discuss with GI\n .\n Elevated Troponin - Discussed with cards, likely demand ischemia in\n setting of anemia v acute MI. would be difficult to heparinize in\n setting of GI bleed. conservative management for now while\n transfusing. got ASA in ED.\n - transfuse for HCT >30 given evidence of ischemia on EKG\n - cycle enzymes\n - repeat EKG\n - continue asa and statin\n - BBlocker I fpressures will allow\n .\n Congestive Heart Failure\n EF 35%\n - juidicious use of lasix given volume patient receiving\n - BBlocker is pressures allow\n .\n Chronic Renal Insufficiency\n Cr below baseline\n - renally dose meds\n .\n Coagulopathy\n INR 1.5 ad trending up since last checked\n - Vitamin K\n .\n Hyperglycemia/IDDM - Pt did not take insulin this am.\n - Regular insulin sliging scale\n .\n Hypertension - Hold BBlocker for now\n .\n Hyperlipidemia - Continue statin and niacin\n .\n # FEN: NPO for now, replete electrolytes, regular diabetic diet\n .\n # Prophylaxis: Pneumoboots, PPI, Bowel Regiman\n .\n # Access: peripherals\n .\n # Code: Full Code\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\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": "2172-03-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370428, "text": "Chief Complaint: Dizzy\n HPI:\n 60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n giving the patient and aspiring, which was done. In addition, the\n patient received 2L NS. CXR showed no acute cardiopulmonary process.\n EKG showed T wave inversions in inferior leads, ST elevation in , \n depression in V5 and V6.\n .\n On arrival to the ICU, vitals 98.5 102 101/55 12 95% on 2L. Pt had no\n complaints. ROS as below. Pt received additional 10 units of insulin\n for persistently elevated blood glucose.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pancreatic Tumor with Abdominal Lymphadenopathy\n Anemia\n Insulin-Dependent Diabetes Mellitus\n Chronic Renal Insufficiency\n Bilateral Hernia Repair age 5\n Congestive Heart Failure\n Coronary artery disease s/p 3-vessel CABG\n Hypertension\n Hyperlipidemia\n Atrial Septal Defect Repair\n Exposure in \n Diabetic Retinopathy\n His father died at the age of 84 from liver\n cancer, had HTN. Mother is in her 80s and alive, had breast ca. He has\n one brother who has asthma, his children are healthy.\n Occupation: IT for \n Drugs: No\n Tobacco: None\n Alcohol: Social 1-2 drinks, 2x week\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, Emesis, No(t) Diarrhea,\n Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Flowsheet Data as of 10:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 92 (92 - 102) bpm\n BP: 102/51(62) {101/51(62) - 102/55(65)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,736 mL\n PO:\n TF:\n IVF:\n 6 mL\n Blood products:\n 130 mL\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,186 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: abdominal LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, shptty, but palpable\n abdominal LAD\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CT Abd - - 1. 4.5-cm spiculated mass centered in the\n distal pancreas, highly concerning for malignancy. Mesenteric nodule\n and umbilical nodules are compatible with metastatic foci.\n 2. Splenomegaly.\n 3. Cholelithiasis, no evidence of acute cholecystitis.\n 4. Limited assessment of solid organs due to lack of IV contrast.\n .\n CXR - - No acute cardiopulmonary process.\n .\n ECG: Regular rate and rhythm, Q waves in II with questionable ST\n segment elevations. New T wave inversion in II, ST segment depression\n in V5 and V6.\n Assessment and Plan\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n 60M with PMH of IDDM, CAD s/p 3 Cabg and new pancreatic mass\n and abdominal lymphadenopathy concerning for metastatic presenting with\n symptomatic anemia.\n .\n Anemia - Anemia malignancy v GI bleed. HCT 25 last week, guaiac\n positive stools in ED. History of coffee ground emesis on capsule\n study. Gastritis and duodenitis on EGD .\n - IV PPI gtt\n - NPO for now\n - transfuse 3 units pRBCs, goal HCT >30\n - HCT q6h\n - consider GI consult for evaluation of GI bleeding and pancreatic mass\n likely EGD in am\n .\n Pancreatic Mass - concerning for malignancy. s/p biopy of umbilical\n nodule\n - f/u path\n - discuss with GI\n .\n Elevated Troponin - Discussed with cards, likely demand ischemia in\n setting of anemia v acute MI. would be difficult to heparinize in\n setting of GI bleed. conservative management for now while\n transfusing. got ASA in ED.\n - transfuse for HCT >30 given evidence of ischemia on EKG\n - cycle enzymes\n - repeat EKG\n - continue asa and statin\n - BBlocker I fpressures will allow\n .\n Congestive Heart Failure\n EF 35%\n - juidicious use of lasix given volume patient receiving\n - BBlocker is pressures allow\n .\n Chronic Renal Insufficiency\n Cr below baseline\n - renally dose meds\n .\n Coagulopathy\n INR 1.5 ad trending up since last checked\n - Vitamin K\n .\n Hyperglycemia/IDDM - Pt did not take insulin this am.\n - Regular insulin sliging scale\n .\n Hypertension - Hold BBlocker for now\n .\n Hyperlipidemia - Continue statin and niacin\n .\n # FEN: NPO for now, replete electrolytes, regular diabetic diet\n .\n # Prophylaxis: Pneumoboots, PPI, Bowel Regiman\n .\n # Access: peripherals\n .\n # Code: Full Code\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\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": "2172-03-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370430, "text": "Chief Complaint: Dizzy\n HPI:\n 60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n giving the patient and aspiring, which was done. In addition, the\n patient received 2L NS. CXR showed no acute cardiopulmonary process.\n EKG showed T wave inversions in inferior leads, ST elevation in , \n depression in V5 and V6.\n .\n On arrival to the ICU, vitals 98.5 102 101/55 12 95% on 2L. Pt had no\n complaints. ROS as below. Pt received additional 10 units of insulin\n for persistently elevated blood glucose.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pancreatic Tumor with Abdominal Lymphadenopathy\n Anemia\n Insulin-Dependent Diabetes Mellitus\n Chronic Renal Insufficiency\n Bilateral Hernia Repair age 5\n Congestive Heart Failure\n Coronary artery disease s/p 3-vessel CABG\n Hypertension\n Hyperlipidemia\n Atrial Septal Defect Repair\n Exposure in \n Diabetic Retinopathy\n His father died at the age of 84 from liver\n cancer, had HTN. Mother is in her 80s and alive, had breast ca. He has\n one brother who has asthma, his children are healthy.\n Occupation: IT for \n Drugs: No\n Tobacco: None\n Alcohol: Social 1-2 drinks, 2x week\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, Emesis, No(t) Diarrhea,\n Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Flowsheet Data as of 10:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 92 (92 - 102) bpm\n BP: 102/51(62) {101/51(62) - 102/55(65)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,736 mL\n PO:\n TF:\n IVF:\n 6 mL\n Blood products:\n 130 mL\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,186 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: abdominal LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, shptty, but palpable\n abdominal LAD\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CT Abd - - 1. 4.5-cm spiculated mass centered in the\n distal pancreas, highly concerning for malignancy. Mesenteric nodule\n and umbilical nodules are compatible with metastatic foci.\n 2. Splenomegaly.\n 3. Cholelithiasis, no evidence of acute cholecystitis.\n 4. Limited assessment of solid organs due to lack of IV contrast.\n .\n CXR - - No acute cardiopulmonary process.\n .\n ECG: Regular rate and rhythm, Q waves in II with questionable ST\n segment elevations. New T wave inversion in II, ST segment depression\n in V5 and V6.\n Assessment and Plan\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n 60M with PMH of IDDM, CAD s/p 3 Cabg and new pancreatic mass\n and abdominal lymphadenopathy concerning for metastatic presenting with\n symptomatic anemia.\n .\n Anemia - Anemia malignancy v GI bleed. HCT 25 last week, guaiac\n positive stools in ED. History of coffee ground emesis on capsule\n study. Gastritis and duodenitis on EGD .\n - IV PPI gtt\n - NPO for now\n - transfuse 3 units pRBCs, goal HCT >30\n - HCT q6h\n - consider GI consult for evaluation of GI bleeding and pancreatic mass\n likely EGD in am\n .\n Pancreatic Mass - concerning for malignancy. s/p biopy of umbilical\n nodule\n - f/u path\n - discuss with GI\n .\n Elevated Troponin - Discussed with cards, likely demand ischemia in\n setting of anemia v acute MI. would be difficult to heparinize in\n setting of GI bleed. conservative management for now while\n transfusing. got ASA in ED.\n - transfuse for HCT >30 given evidence of ischemia on EKG\n - cycle enzymes\n - repeat EKG\n - continue asa and statin\n - BBlocker I fpressures will allow\n .\n Congestive Heart Failure\n EF 35%\n - juidicious use of lasix given volume patient receiving\n - BBlocker is pressures allow\n .\n Chronic Renal Insufficiency\n Cr below baseline\n - renally dose meds\n .\n Coagulopathy\n INR 1.5 ad trending up since last checked\n - Vitamin K\n .\n Hyperglycemia/IDDM - Pt did not take insulin this am.\n - Regular insulin sliging scale\n .\n Hypertension - Hold BBlocker for now\n .\n Hyperlipidemia - Continue statin and niacin\n .\n # FEN: NPO for now, replete electrolytes, regular diabetic diet\n .\n # Prophylaxis: Pneumoboots, PPI, Bowel Regiman\n .\n # Access: peripherals\n .\n # Code: Full Code\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Chart reviewed, patient examined, case discussed in detail with Dr.\n \n. I agree with her note above. In addition, I would\n add/emphasize:\n 60M w/ PMHx sig for known CAD (s/p CABG and recent + stress test),\n recently dx presumed metastatic pancreatic cancer, s/p bx of umbilical\n node. Referred post bx to ED, found to have hct 20, EKG changes ST\n elev inf leads, ST depressions V5, V6, I, avL with Trop bump 0.27 to\n 1.17.\n Demand ischemia\n Cardiology consulted, recommend aspirin, beta blocker if tolerated.\n Transfusing pRBC to goal hct 30 given demand ischemia. Ischemia likely\n demand mediated and not related to plaque rupture. Best treatment\n improve oxygen carrying capacity through pRBC.\n CHF\n Follow fluid status closely given h/o CHF\n latest EF 35%. If sats\n dropping with pRBC, lasix between units.\n Hyponatremia\n Likely pseudohyponatremia due to elevated glucose. No intervention at\n this time\n Hyperglycemia\n FSG 700s, spilling glucose in urine, no ketones, gap already closed.\n Glucose falling already down to 300s. sliding scale is fine though if\n jumps back up, insulin drip. Let doc know pt is in house.\n Presumed metastatic pancreatic cancer\n s/p umbilical node bx. Mult nodules throughout mesentery.\n Remainder of plan per Dr. \n\ns note above.\n Patient is critical ill. Time spent on care: 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:56 ------\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370431, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented to the ED with dizziness,HCt 19,as per the pt he had\n black dark stool in the am,no bm in after coming in the icu.\n Action:\n Received 3u PRBC,received protonix bolus and on protonix drip,contd\n home meds\n Response:\n Rpt hct 19.5\n Plan:\n Goal hct >30,check hct q6h,cont IV PPI\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt known CAD,s/p triple bypass,presented with STT changes,rpt Troponin\n 1.27,denied any chest pain/sob,received aspirin in the ED\n Action:\n Cycled cardiac enzymes,contd tele monitoring,received lasix 10 mg IV\n Response:\n pending\n Plan:\n Will start lopressor once BP stable\n Hyperglycemia\n Assessment:\n Known IDDM,pt didn\nt take insulin last day,presented with a blood sugar\n of ~700,received 10 U reg insulin IV in the ED,rpt FS in the 489 in\n the ED,pt was 440 at the time of presentation in the micu\n Action:\n Received 20 u reg insulin sc(10+10)\n Response:\n pending\n Plan:\n Cont to follow aggressive sliding scale.\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370443, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented to the ED with dizziness,HCt 19,as per the pt he had\n black dark stool in the am,no bm in after coming in the icu.\n Action:\n Received 4u PRBC,received protonix bolus and on protonix drip,contd\n home meds\n Response:\n Rpt hct 19.5.\n Plan:\n Goal hct >30,check hct q6h(next 1030 am)cont IV PPI,?plan for endoscopy\n in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt known CAD,s/p triple bypass,presented with STT changes,rpt Troponin\n 1.17,denied any chest pain/sob,received aspirin in the ED\n Action:\n Cycled cardiac enzymes,contd tele monitoring,received lasix 10 mg IV\n Response:\n Sbp 90-120,hr 80,does goes to 110\ns with exertion,\n Plan:\n Will start lopressor once BP stable\n Hyperglycemia\n Assessment:\n Known IDDM,pt didn\nt take insulin last day,presented with a blood sugar\n of ~700,received 10 U reg insulin IV in the ED,rpt FS in the 489 in\n the ED,pt was 440 at the time of presentation in the micu\n Action:\n Received 20 u reg insulin sc(10+10),monitored fs q2-3 hrly.\n Response:\n 0400am fs 199.\n Plan:\n Cont to follow aggressive sliding scale.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370519, "text": "60 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented with a hct 19,received &U prbc since admission,rpt hct\n 27.7 last pm.no c/o dizziness\n Action:\n Received 1 U Prbc in this shift,followed hct q6h\n Response:\n Rpt hct 31.6\n Plan:\n Goal Hct >30,if EKG with out any changes possible egd today\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for MI,no c/o chest pain\n Action:\n Cycled cardiac enzymes,tele monitoring,contd metoprolol,received Lasix\n 20 mg iv\n Response:\n Sats mid 90\ns,hr 70\ns,sbp 100-130,trop trending down.\n Plan:\n Follow cardiac enzymes,need echocardiogram.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370514, "text": "60 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented with a hct 19,received &U prbc since admission,rpt hct\n 27.7 last pm.no c/o dizziness\n Action:\n Received 1 U Prbc in this shift,followed hct q6h\n Response:\n Rpt hct 31.6\n Plan:\n Goal Hct >30,if EKG with out any changes possible egd today\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruled in for MI,no c/o chest pain\n Action:\n Cycled cardiac enzymes,tele monitoring,contd metoprolol,received Lasix\n 20 mg iv\n Response:\n Sats mid 90\ns,hr 70\ns,sbp 100-130,trop trending down.\n Plan:\n Follow cardiac enzymes\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370510, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt presented to the ED with dizziness,HCt 19,as per the pt he had\n black dark stool in the am,no bm in after coming in the icu.\n Action:\n Received 4u PRBC,received protonix bolus and on protonix drip,contd\n home meds\n Response:\n Rpt hct 25.8 after 4u prbc\n Plan:\n Goal hct >30,check hct q6h(next 1030 am)cont IV PPI,?plan for endoscopy\n in am.plan to give 2 more unit of prbc\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt known CAD,s/p triple bypass,presented with STT changes,rpt Troponin\n 1.17,denied any chest pain/sob,received aspirin in the ED\n Action:\n Cycled cardiac enzymes,contd tele monitoring,received lasix 10 mg IV\n Response:\n Sbp 90-120,hr 80,does goes to 110\ns with exertion,rpt cardiac enzymes\n at 0400am shows worsening with troponin 2.40\n Plan:\n Will start lopressor once BP stable\n Hyperglycemia\n Assessment:\n Known IDDM,pt didn\nt take insulin last day,presented with a blood sugar\n of ~700,received 10 U reg insulin IV in the ED,rpt FS in the 489 in\n the ED,pt was 440 at the time of presentation in the micu\n Action:\n Received 20 u reg insulin sc(10+10),monitored fs q2-3 hrly.\n Response:\n 0400am fs 199.\n Plan:\n Cont to follow aggressive sliding scale.\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370506, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Events- Transfused 2u prbc and 1 u ffp.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hr 70-80 nsr. Sbp 120-130. No signs of active bleeding. No stool or\n emesis today.\n Action:\n Received 2 u prbc today without signs or symptoms of reaction. Also\n received 1 u ffp. Protonix drip changed to protonix 40mg iv.\n Response:\n Hct up to 28.2 post transfusion. Dr made aware. Held off on\n giving more blood till hct at 1700 27.7. Dr made aware. To\n receive 1u prbc.\n Plan:\n Plan not to scope due to rising cardiac indices at this time. Follow\n hcts q 6 hours as ordered. Transfuse 1u prbc.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No c/o of cp or sob. Bs clear with crackles at the bases.\n Action:\n Cardiac indices drawn as ordered. Ekg done this am.\n Response:\n Troponin up to 2.55 from 2.40 at 1100. At 1700 down to 2.4. ck down to\n 335 from 405. per micu team ekg unchanged from day previous.\n Plan:\n Cont to cylcle ck\ns as ordered.\n Hyperglycemia\n Assessment:\n Bs 253 this am.\n Action:\n This was treated with 12u reg per ss. Micu team ordered\n dose of nph\n and changed ss.\n Response:\n Bs 219 at noon tx with 6 u reg per ss.\n Plan:\n Bs as ordered. nph at half his normal dose while he is npo. Qid\n fingerskicks with ss insulin.\n" }, { "category": "Physician ", "chartdate": "2172-03-10 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370489, "text": "Chief Complaint: anemia\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 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n 24 Hour Events:\n - Overnight, got 6 U PRBCs and 1 U FFP. No continued evidence of\n bleeding, has not had a BM since here.\n - Fingersticks down to 200s.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:28 PM\n Furosemide (Lasix) - 02:15 AM\n Other medications:\n colace, omeprazole, lipitor, niacin\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 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.5\n HR: 80 (77 - 102) bpm\n BP: 130/70(85) {94/46(56) - 130/72(87)} mmHg\n RR: 21 (10 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,186 mL\n 1,789 mL\n PO:\n 100 mL\n TF:\n IVF:\n 21 mL\n 87 mL\n Blood products:\n 465 mL\n 1,702 mL\n Total out:\n 550 mL\n 1,850 mL\n Urine:\n 550 mL\n 1,850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,636 mL\n -61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 2L NC\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, umbilical bx site\n c/d/i\n Extremities: Right: Absent, Left: Absent, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 133 K/uL\n 166 mg/dL\n 2.7 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 70 mg/dL\n 105 mEq/L\n 135 mEq/L\n 25.8 %\n 5.0 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n WBC\n 5.0\n Hct\n 19.5\n 25.8\n Plt\n 133\n Cr\n 2.6\n 2.7\n TropT\n 1.17\n 2.40\n Glucose\n 286\n 166\n Other labs: PT / PTT / INR:14.7/26.1/1.3, CK / CKMB /\n Troponin-T:405/38/2.40, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR in the ED with LLL opacity although lateral is clear\n ECG: ECG this AM with persistent ST elevations in III and AVF, ST\n depressions in 1 and avL (stable from last night but different from\n baseline)\n Assessment and Plan\n Problems:\n 1. GI bleed\n 2. Diabetes\n 3. Myocardial ischemia\n 60 y/o M w/likely pancreatic adenocarcinoma, admitted with a GI bleed,\n found to have positive cardiac biomarkers, and hyperglycemia. Is now\n getting his 6th unit of PRBCs; he has remained hemodynamically stable.\n Source concerning for upper GI bleed; has had gastritis in the past but\n also has mass which is potentially eroding into the greater curvature\n of the stomach. GI will see him today and will likely need EGD. Will\n check hematocrits q6h and continue protonix gtt. Will consult\n Cardiology given his ECG changes and positive cardiac enzymes, which\n per the ED was felt by them to be due to demand in the setting of\n anemia. Hyperglycemia resolved with insulin.\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\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: 30 minutes\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n Mr. is a 60 M with suspicion for pancreatic adenocarcinoma, here\n with a severe GI bleed who is now receiving his 6^th unit of PRBC. Also\n found to have positive cardiac biomarkers and hyperglycemia. His BP\n has remained stable. He likely has an upper GI source - he has a h/o\n gastritis but there\ns also concern for the mass eroding into the\n greater curvature of the stomach.\n His exam is notable for stable vitals and a benign abdomen.\n His Hct has improved from 19 to 28.\n GI has been made aware and an EGD is likely. His hematocrit is being\n checked every 6 hours. He is on a protonix gtt.\n Will discuss the cardiac enzymes and EKG changes with his outpatient\n Cardiologist.\n We will follow the hyperglycemia which has resolved with insulin.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:29 ------\n" }, { "category": "Physician ", "chartdate": "2172-03-10 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370490, "text": "Chief Complaint: anemia\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 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n 24 Hour Events:\n - Overnight, got 6 U PRBCs and 1 U FFP. No continued evidence of\n bleeding, has not had a BM since here.\n - Fingersticks down to 200s.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:28 PM\n Furosemide (Lasix) - 02:15 AM\n Other medications:\n colace, omeprazole, lipitor, niacin\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 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.5\n HR: 80 (77 - 102) bpm\n BP: 130/70(85) {94/46(56) - 130/72(87)} mmHg\n RR: 21 (10 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,186 mL\n 1,789 mL\n PO:\n 100 mL\n TF:\n IVF:\n 21 mL\n 87 mL\n Blood products:\n 465 mL\n 1,702 mL\n Total out:\n 550 mL\n 1,850 mL\n Urine:\n 550 mL\n 1,850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,636 mL\n -61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 2L NC\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, umbilical bx site\n c/d/i\n Extremities: Right: Absent, Left: Absent, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 133 K/uL\n 166 mg/dL\n 2.7 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 70 mg/dL\n 105 mEq/L\n 135 mEq/L\n 25.8 %\n 5.0 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n WBC\n 5.0\n Hct\n 19.5\n 25.8\n Plt\n 133\n Cr\n 2.6\n 2.7\n TropT\n 1.17\n 2.40\n Glucose\n 286\n 166\n Other labs: PT / PTT / INR:14.7/26.1/1.3, CK / CKMB /\n Troponin-T:405/38/2.40, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR in the ED with LLL opacity although lateral is clear\n ECG: ECG this AM with persistent ST elevations in III and AVF, ST\n depressions in 1 and avL (stable from last night but different from\n baseline)\n Assessment and Plan\n Problems:\n 1. GI bleed\n 2. Diabetes\n 3. Myocardial ischemia\n 60 y/o M w/likely pancreatic adenocarcinoma, admitted with a GI bleed,\n found to have positive cardiac biomarkers, and hyperglycemia. Is now\n getting his 6th unit of PRBCs; he has remained hemodynamically stable.\n Source concerning for upper GI bleed; has had gastritis in the past but\n also has mass which is potentially eroding into the greater curvature\n of the stomach. GI will see him today and will likely need EGD. Will\n check hematocrits q6h and continue protonix gtt. Will consult\n Cardiology given his ECG changes and positive cardiac enzymes, which\n per the ED was felt by them to be due to demand in the setting of\n anemia. Hyperglycemia resolved with insulin.\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\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: 30 minutes\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n Mr. is a 60 M with suspicion for pancreatic adenocarcinoma, here\n with a severe GI bleed who is now receiving his 6^th unit of PRBC. Also\n found to have positive cardiac biomarkers and hyperglycemia. His BP\n has remained stable. He likely has an upper GI source - he has a h/o\n gastritis but there\ns also concern for the mass eroding into the\n greater curvature of the stomach.\n His exam is notable for stable vitals and a benign abdomen.\n His Hct has improved from 19 to 28.\n GI has been made aware and an EGD is likely. His hematocrit is being\n checked every 6 hours. He is on a protonix gtt.\n Will discuss the cardiac enzymes and EKG changes with his outpatient\n Cardiologist.\n We will follow the hyperglycemia which has resolved with insulin.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:29 ------\n cc time: 35\n ------ Protected Section Addendum Entered By: , MD\n on: 16:32 ------\n" }, { "category": "Physician ", "chartdate": "2172-03-10 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370460, "text": "Chief Complaint: anemia\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 y/o M w/CAD s/p CABG , DM, anemia, who presented yesterday with\n nausea, vomiting, and lightheadedness. Found to have Hct 20, glucose\n 700. Ruled in for MI. Got 2L NS and admitted him to the MICU.\n 24 Hour Events:\n - Overnight, got 6 U PRBCs and 1 U FFP. No continued evidence of\n bleeding, has not had a BM since here.\n - Fingersticks down to 200s.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:28 PM\n Furosemide (Lasix) - 02:15 AM\n Other medications:\n colace, omeprazole, lipitor, niacin\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 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.5\n HR: 80 (77 - 102) bpm\n BP: 130/70(85) {94/46(56) - 130/72(87)} mmHg\n RR: 21 (10 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,186 mL\n 1,789 mL\n PO:\n 100 mL\n TF:\n IVF:\n 21 mL\n 87 mL\n Blood products:\n 465 mL\n 1,702 mL\n Total out:\n 550 mL\n 1,850 mL\n Urine:\n 550 mL\n 1,850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,636 mL\n -61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 2L NC\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, umbilical bx site\n c/d/i\n Extremities: Right: Absent, Left: Absent, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 133 K/uL\n 166 mg/dL\n 2.7 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 70 mg/dL\n 105 mEq/L\n 135 mEq/L\n 25.8 %\n 5.0 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n WBC\n 5.0\n Hct\n 19.5\n 25.8\n Plt\n 133\n Cr\n 2.6\n 2.7\n TropT\n 1.17\n 2.40\n Glucose\n 286\n 166\n Other labs: PT / PTT / INR:14.7/26.1/1.3, CK / CKMB /\n Troponin-T:405/38/2.40, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR in the ED with LLL opacity although lateral is clear\n ECG: ECG this AM with persistent ST elevations in III and AVF, ST\n depressions in 1 and avL (stable from last night but different from\n baseline)\n Assessment and Plan\n Problems:\n 1. GI bleed\n 2. Diabetes\n 3. Myocardial ischemia\n 60 y/o M w/likely pancreatic adenocarcinoma, admitted with a GI bleed,\n found to have positive cardiac biomarkers, and hyperglycemia. Is now\n getting his 6th unit of PRBCs; he has remained hemodynamically stable.\n Source concerning for upper GI bleed; has had gastritis in the past but\n also has mass which is potentially eroding into the greater curvature\n of the stomach. GI will see him today and will likely need EGD. Will\n check hematocrits q6h and continue protonix gtt. Will consult\n Cardiology given his ECG changes and positive cardiac enzymes, which\n per the ED was felt by them to be due to demand in the setting of\n anemia. Hyperglycemia resolved with insulin.\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\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: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370562, "text": "Aemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n No stool today. Abd soft with pos bs. No c/o of pain. Hct stable at 32.\n Action:\n Seen by Gi. They did not want to scope today due to strain seen on\n today\ns ekg. Started patient on clear liquids.\n Response:\n Tolerating clear liquids well. No c/o.\n Plan:\n Repeat hct at 1700. Npo after mn tonight for ? scope in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-90 nsr without ectopi. No c/o of cp or sob. Sats 97-99% on ra.\n Troponin down to 1.71.\n Action:\n Cardiac echo done. Ekg done. Lopressor increased to 25mg po bid.\n Response:\n Hr presently in the 70\ns. No c/o of pain.\n Plan:\n Ekg in am.\n Hyperglycemia\n Assessment:\n Bs this am 219.\n Action:\n Tx with homologue. nph dosing increased to 15u from 10 u .\n Response:\n Bs at noon was 248. He was tx with ss homologue and received 5 u mph to\n make 15u for the am.\n Plan:\n QID bs.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370563, "text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n No stool today. Abd soft with pos bs. No c/o of pain. Hct stable at 32.\n Action:\n Seen by Gi. They did not want to scope today due to strain seen on\n today\ns ekg. Started patient on clear liquids.\n Response:\n Tolerating clear liquids well. No c/o.\n Plan:\n Repeat hct at 1700. Npo after mn tonight for ? scope in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-90 nsr without ectopi. No c/o of cp or sob. Sats 97-99% on ra.\n Troponin down to 1.71.\n Action:\n Cardiac echo done. Ekg done. Lopressor increased to 25mg po bid.\n Response:\n Hr presently in the 70\ns. No c/o of pain.\n Plan:\n Ekg in am.\n Hyperglycemia\n Assessment:\n Bs this am 219.\n Action:\n Tx with homologue. nph dosing increased to 15u from 10 u .\n Response:\n Bs at noon was 248. He was tx with ss homologue and received 5 u mph to\n make 15u for the am.\n Plan:\n QID bs.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370564, "text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n No stool today. Abd soft with pos bs. No c/o of pain. Hct stable at 32.\n Action:\n Seen by Gi. They did not want to scope today due to strain seen on\n today\ns ekg. Started patient on clear liquids.\n Response:\n Tolerating clear liquids well. No c/o.\n Plan:\n Repeat hct at 1700. Npo after mn tonight for ? scope in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-90 nsr without ectopi. No c/o of cp or sob. Sats 97-99% on ra.\n Troponin down to 1.71.\n Action:\n Cardiac echo done. Ekg done. Lopressor increased to 25mg po bid.\n Response:\n Hr presently in the 70\ns. No c/o of pain.\n Plan:\n Ekg in am.\n Hyperglycemia\n Assessment:\n Bs this am 219.\n Action:\n Tx with homologue. nph dosing increased to 15u from 10 u .\n Response:\n Bs at noon was 248. He was tx with ss homologue and received 5 u mph to\n make 15u for the am.\n Plan:\n QID bs.\n 60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370548, "text": "60M with PMH of IDDM, CAD s/p 3 CABG, gastritis and new\n pancreatic who presents with GIB, anemia, and NSTEMI\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Cardiac echo done.\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2172-03-11 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370550, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60 y/o M w/significant coronary disease, admitted with GI bleed.\n 24 Hour Events:\n - has only required one unit of blood since yesterday; no bowel\n movements\n - got one dose of lasix with blood\n - cardiac enzymes continue to trend down\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:18 PM\n Pantoprazole (Protonix) - 12:08 AM\n Other medications:\n colace, lipitor, iron, calcitriol, niacin, protonix 40 IV bid, insulin\n fixed dose & sliding scale, lopressor 12.5 \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 10:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.6\n HR: 79 (70 - 94) bpm\n BP: 127/75(89) {105/51(63) - 137/85(96)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,593 mL\n 10 mL\n PO:\n TF:\n IVF:\n 125 mL\n 10 mL\n Blood products:\n 2,468 mL\n Total out:\n 4,675 mL\n 1,350 mL\n Urine:\n 4,675 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,082 mL\n -1,340 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar)\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: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.2 g/dL\n 139 K/uL\n 134 mg/dL\n 2.4 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.0 %\n 4.1 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n 10:51 AM\n 05:03 PM\n 10:50 PM\n 04:09 AM\n WBC\n 5.0\n 4.9\n 4.3\n 4.1\n Hct\n 19.5\n 25.8\n 28.2\n 27.7\n 31.6\n 32.0\n Plt\n 133\n 125\n 123\n 139\n Cr\n 2.6\n 2.7\n 2.4\n TropT\n 1.17\n 2.40\n 2.55\n 2.40\n 1.71\n Glucose\n 286\n 166\n 134\n Other labs: PT / PTT / INR:14.2/25.5/1.2, CK / CKMB /\n Troponin-T:133/11/1.71, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n LDH:228 IU/L, Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: Fingersticks in 150s-low 200s\n ECG: ECG this AM pending\n Assessment and Plan\n 60 y/o M w/coronary history, who presented with anemia and also ruled\n in for an MI with ischemic ECG changes. His hematocrit has been stable\n and he has had no further clinical evidence of bleeding. Will discuss\n with GI whether they want to proceed with EGD now that cardiac enzymes\n are trending down (will also repeat ECG this AM to see if changes have\n resolved). We are holding aspirin given his GI bleed, he is on a\n beta-blocker and has room for uptitration. Had an echo this morning\n which is pending.\n ICU Care\n Nutrition:\n Comments: NPO pending EGD\n Glycemic Control: Comments: Increase NPH\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2172-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370551, "text": "Chief Complaint: GI bleed, NSTEMI\n 24 Hour Events:\n Cards- TTE to assess regional WMA, hold ASA per attdg for now, GI\n aggres, daily ECG, transfuse HCT 30 with lasix\n GI- hold on EGD until hct stable and cardiac issues stable\n transfused 1 unit for hct 27, lasix 20mg IV given\n startes metoprolol \n 11PM HCT 32\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:18 PM\n Pantoprazole (Protonix) - 12:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea\n Respiratory: No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 81 (70 - 94) bpm\n BP: 127/63(78) {105/51(63) - 137/85(96)} mmHg\n RR: 8 (8 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,593 mL\n 10 mL\n PO:\n TF:\n IVF:\n 125 mL\n 10 mL\n Blood products:\n 2,468 mL\n Total out:\n 4,675 mL\n 800 mL\n Urine:\n 4,675 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,082 mL\n -790 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 139 K/uL\n 11.2 g/dL\n 134 mg/dL\n 2.4 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.0 %\n 4.1 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n 10:51 AM\n 05:03 PM\n 10:50 PM\n 04:09 AM\n WBC\n 5.0\n 4.9\n 4.3\n 4.1\n Hct\n 19.5\n 25.8\n 28.2\n 27.7\n 31.6\n 32.0\n Plt\n 133\n 125\n 123\n 139\n Cr\n 2.6\n 2.7\n 2.4\n TropT\n 1.17\n 2.40\n 2.55\n 2.40\n 1.71\n Glucose\n 286\n 166\n 134\n Other labs: PT / PTT / INR:14.2/25.5/1.2, CK / CKMB /\n Troponin-T:133/11/1.71, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n LDH:228 IU/L, Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n HYPERGLYCEMIA\n ANEMIA, CHRONIC\n 60M with PMH of IDDM, CAD s/p 3 CABG, gastritis and new\n pancreatic who presents with GIB, anemia, and NSTEMI\n .\n Acute Blood Loss Anemia/GIB\n Hemodynamically stable. Guaic + stool\n makes GIB most likely. be gastritis vs. related to pancreatic\n mass. Recent colonoscopy unremarkable. No abd pain to suggest\n intra-abdominal hemorrhage. s/p 7 units prbcs and 1 unit platelets.\n Gastritis and duodenitis on EGD . Hct now stable\n - IV PPI \n - NPO for now\n - IVF\n - Active T/S, transfuse for hct<30\n - HCT \n - Appreciate GI recs -> will scope once cards issue stable ? today\n .\n NSTEMI/CAD\n Trop peak at 2.7. EKG with lateral ST depressions. Ces\n now trending down. Has remained asymptomatic. Likely demand related.\n - Cont to trend CEs\n - Daily EKG\n - Appreciate Cards input: will hold ASA for now\n - Restarted BB -> resume home dose today (25mg )\n - Cont statin, hold ACE-I for now until GIB stable\n - TTE to assess cardiac function\n .\n Pancreatic Mass - concerning for malignancy. s/p biopy of umbilical\n nodule\n - f/u path\n - discuss with GI\n .\n Congestive Heart Failure\n EF 35% by recent echo. Clinically euvolemic\n and well compensated. Likely related to ischemic CMO.\n - Give lasix with each unit prbcs\n - Resumed BB, increase to home dose\n - Restart ACE-I ASAP\n - Cont statin\n - Check TTE today\n .\n CKD: Stable. Cont to follow\n .\n Diabetes: Cont HISS and increase NPH to 15units (home dose 20 units\n )\n .\n Hypertension\n Restart BB, hold ACE-I\n .\n Hyperlipidemia - Continue statin and niacin\n .\n FEN: NPO for now, replete electrolytes, regular diabetic diet\n - IVF\n .\n Prophylaxis: Pneumoboots, PPI, Bowel Regiman\n .\n Access: peripherals\n .\n Code: Full Code\n .\n Communication: Patient\n .\n Disposition: pending above, will call out to vs. medicine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370560, "text": "60M with PMH of IDDM, CAD s/p 3 CABG, gastritis and new\n pancreatic who presents with GIB, anemia, and NSTEMI\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n No stool today. Abd soft with pos bs. No c/o of pain. Hct stable at 32.\n Action:\n Seen by Gi. They did not want to scope today due to strain seen on\n today\ns ekg. Started patient on clear liquids.\n Response:\n Tolerating clear liquids well. No c/o.\n Plan:\n Repeat hct at 1700. Npo after mn tonight for ? scope in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-90 nsr without ectopi. No c/o of cp or sob. Sats 97-99% on ra.\n Troponin down to 1.71.\n Action:\n Cardiac echo done. Ekg done. Lopressor increased to 25mg po bid.\n Response:\n Hr presently in the 70\ns. No c/o of pain.\n Plan:\n Ekg in am.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2172-03-11 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370561, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60 y/o M w/significant coronary disease, admitted with GI bleed.\n 24 Hour Events:\n - has only required one unit of blood since yesterday; no bowel\n movements\n - got one dose of lasix with blood\n - cardiac enzymes continue to trend down\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:18 PM\n Pantoprazole (Protonix) - 12:08 AM\n Other medications:\n colace, lipitor, iron, calcitriol, niacin, protonix 40 IV bid, insulin\n fixed dose & sliding scale, lopressor 12.5 \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 10:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.6\n HR: 79 (70 - 94) bpm\n BP: 127/75(89) {105/51(63) - 137/85(96)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,593 mL\n 10 mL\n PO:\n TF:\n IVF:\n 125 mL\n 10 mL\n Blood products:\n 2,468 mL\n Total out:\n 4,675 mL\n 1,350 mL\n Urine:\n 4,675 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,082 mL\n -1,340 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar)\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: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.2 g/dL\n 139 K/uL\n 134 mg/dL\n 2.4 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.0 %\n 4.1 K/uL\n [image002.jpg]\n 11:34 PM\n 04:25 AM\n 10:51 AM\n 05:03 PM\n 10:50 PM\n 04:09 AM\n WBC\n 5.0\n 4.9\n 4.3\n 4.1\n Hct\n 19.5\n 25.8\n 28.2\n 27.7\n 31.6\n 32.0\n Plt\n 133\n 125\n 123\n 139\n Cr\n 2.6\n 2.7\n 2.4\n TropT\n 1.17\n 2.40\n 2.55\n 2.40\n 1.71\n Glucose\n 286\n 166\n 134\n Other labs: PT / PTT / INR:14.2/25.5/1.2, CK / CKMB /\n Troponin-T:133/11/1.71, Amylase / Lipase:, Fibrinogen:235 mg/dL,\n LDH:228 IU/L, Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: Fingersticks in 150s-low 200s\n ECG: ECG this AM pending\n Assessment and Plan\n 60 y/o M w/coronary history, who presented with anemia and also ruled\n in for an MI with ischemic ECG changes. His hematocrit has been stable\n and he has had no further clinical evidence of bleeding. Will discuss\n with GI whether they want to proceed with EGD now that cardiac enzymes\n are trending down (will also repeat ECG this AM to see if changes have\n resolved). We are holding aspirin given his GI bleed, he is on a\n beta-blocker and has room for uptitration. Had an echo this morning\n which is pending.\n ICU Care\n Nutrition:\n Comments: NPO pending EGD\n Glycemic Control: Comments: Increase NPH\n Lines:\n 18 Gauge - 08:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:41 ------\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370483, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Events- Transfused 2u prbc and 1 u ffp.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hr 70-80 nsr. Sbp 120-130. No signs of active bleeding. No stool or\n emesis today.\n Action:\n Received 2 u prbc today without signs or symptoms of reaction. Also\n received 1 u ffp. Protonix drip changed to protonix 40mg iv.\n Response:\n Hct up to 28.2 post transfusion. Goal is hct 30. team will see what hct\n is at 1700 till they decide to give blood or not.\n Plan:\n Plan not to scope due to rising cardiac indices at this time. Follow\n hcts q 6 hours as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No c/o of cp or sob. Bs clear with crackles at the bases.\n Action:\n Cardiac indices drawn as ordered\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Bs 253 this am.\n Action:\n This was treated with 12u reg per ss. Micu team ordered\n dose of nph\n and changed ss.\n Response:\n Bs 219 at noon tx with 6 u reg per ss.\n Plan:\n Bs as ordered. nph at half his normal dose while he is npo. Qid\n fingerskicks with ss insulin.\n" }, { "category": "Nursing", "chartdate": "2172-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370484, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n Events- Transfused 2u prbc and 1 u ffp.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hr 70-80 nsr. Sbp 120-130. No signs of active bleeding. No stool or\n emesis today.\n Action:\n Received 2 u prbc today without signs or symptoms of reaction. Also\n received 1 u ffp. Protonix drip changed to protonix 40mg iv.\n Response:\n Hct up to 28.2 post transfusion. Goal is hct 30. team will see what hct\n is at 1700 till they decide to give blood or not.\n Plan:\n Plan not to scope due to rising cardiac indices at this time. Follow\n hcts q 6 hours as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No c/o of cp or sob. Bs clear with crackles at the bases.\n Action:\n Cardiac indices drawn as ordered. Ekg done this am.\n Response:\n Troponin up to 2.55 from 2.40. ck down to 335 from 405. per micu team\n ekg unchanged from day previous.\n Plan:\n Cont to cylcle ck\ns as ordered.\n Hyperglycemia\n Assessment:\n Bs 253 this am.\n Action:\n This was treated with 12u reg per ss. Micu team ordered\n dose of nph\n and changed ss.\n Response:\n Bs 219 at noon tx with 6 u reg per ss.\n Plan:\n Bs as ordered. nph at half his normal dose while he is npo. Qid\n fingerskicks with ss insulin.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370565, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370567, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n He r/I for an mi. Required 7u prbc and 1 u ffp. Not scoped as of yet\n due to strain seen on ekg. Plan is for scope in am if cardiology ok\n with scoping patient.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n ANEMIA\n Code status:\n Full code\n Height:\n Admission weight:\n 86.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, GI Bleed\n CV-PMH: CAD, CHF\n Additional history: pancreatic ca,s/p triple bypass in ,CRI,\n Surgery / Procedure and date: s/p cabg in ,\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:149\n D:88\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 410 mL\n 24h total out:\n 1,350 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:09 AM\n Potassium:\n 3.8 mEq/L\n 04:09 AM\n Chloride:\n 107 mEq/L\n 04:09 AM\n CO2:\n 22 mEq/L\n 04:09 AM\n BUN:\n 49 mg/dL\n 04:09 AM\n Creatinine:\n 2.4 mg/dL\n 04:09 AM\n Glucose:\n 134 mg/dL\n 04:09 AM\n Hematocrit:\n 32.0 %\n 04:09 AM\n Finger Stick Glucose:\n 248\n 12:00 PM\n Valuables / Signature\n Patient valuables: phone, eyeglasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n No stool today. Abd soft with pos bs. No c/o of pain. Hct stable at 32.\n Action:\n Seen by Gi. They did not want to scope today due to strain seen on\n today\ns ekg. Started patient on clear liquids.\n Response:\n Tolerating clear liquids well. No c/o.\n Plan:\n Repeat hct at 1700. Npo after mn tonight for ? scope in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-90 nsr without ectopi. No c/o of cp or sob. Sats 97-99% on ra.\n Troponin down to 1.71.\n Action:\n Cardiac echo done. Ekg done. Lopressor increased to 25mg po bid.\n Response:\n Hr presently in the 70\ns. No c/o of pain.\n Plan:\n Ekg in am.\n Hyperglycemia\n Assessment:\n Bs this am 219.\n Action:\n Tx with homologue. nph dosing increased to 15u from 10 u .\n Response:\n Bs at noon was 248. He was tx with ss homologue and received 5 u mph to\n make 15u for the am.\n Plan:\n QID bs.\n" }, { "category": "Nursing", "chartdate": "2172-03-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370568, "text": "60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents\n with one day of dizziness. The patient states that he woke up at 4am\n to go to the bathroom this morning and felt dizzy. He returned to bed\n and was persistenly dizzy with all subsequent attempts to get out of\n bed. Patient notes that he had a dark bowel movement this morning.\n He also vomited once this orning. This afternoon, he came to\n dermatology clinic for scheduled biopsy of an umbilic nodule. On\n , the patient had had a CT scan of his abdomen that revealed a\n 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning\n for metastases. Following the derm appointment, the patient came to\n the ED for further evaluation.\n .\n In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA\n Patient did not take his insulin this am and had a blood glucose of 707\n in the ED for which he received 10 units of insulin. Repeat FSBS was\n 489. The patient was also noted to have a positive troponin of .27 and\n an index of 9.1. Cardiology was contact and it was thought to be due\n to demand in the setting of a hematocrit of 20. Cardiology recommended\n ASA which was given. In addition, the patient received 2L NS. CXR\n showed no acute cardiopulmonary process. EKG showed T wave inversions\n in inferior leads, ST elevation in , depression in V5 and V6\n He r/I for an mi. Required 7u prbc and 1 u ffp. Not scoped as of yet\n due to strain seen on ekg. Plan is for scope in am if cardiology ok\n with scoping patient.\n Anemia, acut Anemia secondary to blood loss\n (Hemorrhage, Bleeding)\n Assessment:\n No stool today. Abd soft with pos bs. No c/o of pain. Hct stable at 32.\n Action:\n Seen by Gi. They did not want to scope today due to strain seen on\n today\ns ekg. Started patient on clear liquids.\n Response:\n Tolerating clear liquids well. No c/o.\n Plan:\n Repeat hct at 1700. Npo after mn tonight for ? scope in am.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-90 nsr without ectopi. No c/o of cp or sob. Sats 97-99% on ra.\n Troponin down to 1.71.\n Action:\n Cardiac echo done. Ekg done. Lopressor increased to 25mg po bid.\n Response:\n Hr presently in the 70\ns. No c/o of pain.\n Plan:\n Ekg in am.\n Hyperglycemia\n Assessment:\n Bs this am 219.\n Action:\n Tx with homologue. nph dosing increased to 15u from 10 u .\n Response:\n Bs at noon was 248. He was tx with ss homologue and received 5 u mph to\n make 15u for the am.\n Plan:\n QID bs.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n ANEMIA\n Code status:\n Full code\n Height:\n Admission weight:\n 86.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, GI Bleed\n CV-PMH: CAD, CHF\n Additional history: pancreatic ca,s/p triple bypass in ,CRI,\n Surgery / Procedure and date: s/p cabg in ,\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:149\n D:88\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 410 mL\n 24h total out:\n 1,350 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:09 AM\n Potassium:\n 3.8 mEq/L\n 04:09 AM\n Chloride:\n 107 mEq/L\n 04:09 AM\n CO2:\n 22 mEq/L\n 04:09 AM\n BUN:\n 49 mg/dL\n 04:09 AM\n Creatinine:\n 2.4 mg/dL\n 04:09 AM\n Glucose:\n 134 mg/dL\n 04:09 AM\n Hematocrit:\n 32.0 %\n 04:09 AM\n Finger Stick Glucose:\n 248\n 12:00 PM\n Valuables / Signature\n Patient valuables: phone, eyeglasses\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 793\n Transferred to: cc711\n Date & time of Transfer: \n" }, { "category": "ECG", "chartdate": "2172-03-11 00:00:00.000", "description": "Report", "row_id": 147637, "text": "Sinus rhythm. Prior inferior myocardial infarction. Compared to the previous\ntracing of there is further evolution of recent or ongoing inferior\nmyocardial infarction with continued upward coved ST segments and deepening\nT wave inversions in leads II, III and aVF. In addition, there is low limb\nlead voltage and evidence for prior anteroseptal myocardial infarction. Atrial\nectopy is absent. Followup and clinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2172-03-10 00:00:00.000", "description": "Report", "row_id": 147638, "text": "Sinus rhythm with atrial and ventricular premature beats. Since the previous\ntracing the premature beats are new. Otherwise, no change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2172-03-09 00:00:00.000", "description": "Report", "row_id": 147639, "text": "Sinus rhythm at upper limits of normal rate. Low limb lead voltage.\nST-T wave abnormalities. Since the previous tracing limb lead voltage is\nless. Otherwise, probably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2172-03-09 00:00:00.000", "description": "Report", "row_id": 147640, "text": "Sinus rhythm. Inferior wall myocardial infarction, age indeteminate. Other\nST-T wave abnormalities. Since the previous tracing of the rate has\nincreased. ST-T wave abnormalities are more marked.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2172-03-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1070542, "text": " 5:32 PM\n CHEST (PA & LAT) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with anemia, ekg changes, unclear reasons\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PA AND LATERAL\n\n COMPARISON: .\n\n HISTORY: EKG changes.\n\n FINDINGS: Sternotomy wires and mediastinal clips are again identified,\n unchanged, compatible with prior CABG. The cardiac silhouette is stable.\n There is a tortuous aorta, unchanged. There are low lung volumes. There is\n no focal consolidation, effusion, or pneumothorax. Minimal left basilar\n atelectasis is identified.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2130-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 839671, "text": " 10:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval change\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50M s/p motorcycle accident, with R epidural bleed & temporal fracture\n\n REASON FOR THIS EXAMINATION:\n eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post motorcycle accident with right epidural bleed and\n temporal fracture, assess for interval change.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: Head CT.\n\n HEAD CT w/o CONTRAST: There are stable bilateral subdural hematomas. A tiny\n amount of intraventricular hemorrhage is present. There is stable\n subarachnoid hemorrhage. There is no mass effect and no shift of normally\n midline structures. No new areas of hemorrhage are present. New\n pneumocephalus is present. Small bubbles of gas are seen anterior to the\n right and left frontal lobes. There appears to be more gas exstending above\n the left orbital roof. Stable multiple facial fractures are present.\n\n IMPRESSION\n\n 1. No significant change in the appearance of the subdural hematomas and the\n amount of subarachnoid hemorrhage.\n\n 2. No change in mass effect.\n\n 3. There has been interval development of pneumocephalus, possibly secondary\n to the left orbital roof fracture.\n\n The referring physician, . , was informed of these findings following\n the examination.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-29 00:00:00.000", "description": "LP WRIST(3 + VIEWS) LEFT PORT", "row_id": 839743, "text": " 9:44 AM\n WRIST(3 + VIEWS) LEFT PORT; HAND (AP, LAT & OBLIQUE) LEFT PORT Clip # \n Reason: r/o fracture\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M s/p MVC, facial fractures, now with L hand tenderness...\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55 year old status-post MVC. Now with left hand tenderness.\n\n LEFT HAND, THREE VIEWS. There is a comminuted fracture of the proximal 1st\n metacarpal with mild lateral displacement of the distal fragment. On the\n ulnar side of the proximal portion of the 1st proximal phalanx, there is a\n minimally displaced fracture. Irregularity at the dorsal proximal 1st distal\n phalanx is well corticated and is consistent with a tiny osseous fragment. No\n other fractures are seen. There is normal mineralization. No focal lesions\n are present.\n\n IMPRESSION:\n Comminuted fracture of the proximal left 1st metacarpal and minimally\n displaced fracture of left 1st proximal phalanx.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 839568, "text": " 8:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: RT EPIDURAL BLEED AND TEMPORAL FRACTURE, ASSESS FOR INTERVAL CHANGE.\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50M s/p motorcycle accident, with R epidural bleed & temporal fracture\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motorcycle accident, with right epidural bleed and\n temporal fracture, assess for interval change.\n\n COMPARISONS: CT head of .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS:\n Again identified are multiple skull and facial bone fractures, which show no\n interval change from the previous study.\n\n There is a stable appearance of the bilateral subdural hematomas extending\n into the falx. Additionally, there is a small amount of intraventricular\n blood and mild contusion to the frontal lobe. The distribution of the\n subarachnoid hemorrhage is slightly changed with perhaps slightly more\n prominence of subarachnoid blood in the posterior left frontal lobe, however,\n with interval decrease in the subarachnoid blood in the interpeduncular\n cistern and sylvian fissure on the left. Again, there is no evidence of\n hydrocephalus or shift of normally midline structures.\n\n IMPRESSION: Stable appearance of multiple skull and facial fractures.\n Persistent subdural and subarachnoid hemorrhage as described above, with\n slight change in the distribution of the subarachnoid blood. No evidence of\n hydrocephalus or midline shift. These results were relayed by telephone to\n the requesting emergency physician at approximately 11AM on .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 839413, "text": " 9:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval position & lung inflation\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M s/p open trach\n REASON FOR THIS EXAMINATION:\n eval position & lung inflation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Open tracheostomy. Check lung inflation.\n\n SUPINE PORTABLE AP CHEST: Comparison is made to the torso CT scan from\n earlier the same day. A tracheostomy tube is present with the tip in\n satisfactory position in the mid trachea. Both lungs are relatively well\n inflated. No definite pneumothorax is seen. Cardiac size is stable. Note is\n made of prominent superior mediastinal contours, which are likely\n postoperative in nature. An unfolded aorta also likely contributes. The\n overall appearance is not significantly changed compared to the torso CT scan.\n Patchy areas of opacity are seen in the left upper lobe and both lower lobes,\n likely atelectasis. No definite effusion is seen.\n\n IMPRESSION: Both lungs are relatively well inflated with patchy areas of\n atelectasis in both lungs. Tracheostomy tube in mid trachea.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-25 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 839394, "text": " 5:33 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: S/ , MS, NECK PAIN, ASSESS FX/DISLOCATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/ , ms\n REASON FOR THIS EXAMINATION:\n assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm WED 7:22 PM\n Degenerative changes. No fractures\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHNIQUE: Axial images of the C-spine without IV contrast with sagittal and\n coronal reconstructions.\n\n CT C-SPINE: There is slight irregularity of the lamina of T1 which is likely\n artifactual. There is widening of the facet joint spaces at C4-5 bilaterally,\n which could be degenerative or represent ligamentous injury.\n\n Extensive degenerative changes are seen in the cervical spine at the level of\n C5 through C7 with disc space reduction and osteophytosis. The prevertebral\n soft tissue is unremarkable. There is no paraspinal abnormality seen.\n\n IMPRESSION: No evidence of cervical spine fracture, however, there is\n widening of the C4-5 facet joints and ther could be ligamentous injury.\n Follow-up flexion-extension study, or if the patient is unable, an MR scan\n should be considered if there are clinical signs of cervical injury.\n Discussed with Dr. at 10:50 am on .\n\n" }, { "category": "Radiology", "chartdate": "2130-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 839396, "text": " 5:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/ , MS, ASSESS BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/ , ms\n REASON FOR THIS EXAMINATION:\n assess for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm WED 6:16 PM\n Subdural and subarachnoid hemorrhage. Multiple facial fractures including a\n small depressed right temporal fracture\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHNIQUE: CT head without contrast.\n\n FINDINGS: There is bilateral subdural hemorrhage anterior to the temporal\n lobes. Air is also seen in the left middle cranial fossa, anterior to the\n temporal lobe, and along the inner table of the right frontal skull.\n Subarachnoid hemorrhage is also seen on the left, particularly in the Sylvian\n fissure. There is possible subdural hemorrhage adjacent to the right frontal\n lobe. Brain parenchymal attenuation is preserved. There is no shift of\n normally midline structures or major vascular territory infarction. There is\n no evidence of hydrocephalus.\n\n There are multiple skull and facial bone fractures seen. There are a few\n fracture lines through the right temporal bone, involving squamous and mastoid\n portions. The fracture extends across the epitymapanic cavity and there is\n fluid in the dependent portion of the middle ear. There is left temporal\n squamous fracture. The mastoid air cells are intact.\n\n There are fractures of the maxillary sinuses, ethmoids and lamina papyrecea,\n and lateral orbital walls. There is probably some hematoma in the orbits,\n adjacent to fractured walls, but no major displacement of the orbital\n structures is evident. The globes are intact. Fractures through the zygomatic\n bones bilaterally are also noted. Air- fluid levels are seen in the sphenoid\n sinus, ethmoid air cells and the frontal sinus.\n\n IMPRESSION: Subdural and subarachnoid hemorrhage as described above with\n multiple skull and facial fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-25 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 839397, "text": " 5:34 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: S/ , MS, FACIAL SWELLING, BRUISING, ASSESS FOR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/ , ms\n REASON FOR THIS EXAMINATION:\n assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm WED 7:59 PM\n Multiple facial fractures\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHNIQUE: Axial images of the facial bones with sagittal and coronal\n reconstructions.\n\n FACIAL BONE CT: There are multiple facial bone fractures. These include\n anterior and lateral wall fractures of the maxillary sinuses bilaterally.\n The right fracture fragments are displaced, some into the sinus cavity.\n\n Lamina papyrecea and lateral orbital wall fractures are also noted\n bilaterally. There are fractures through the inferior orbital rims and orbital\n floors, but no herniation of orbital contents. There is a fracture through the\n right orbital roof, with fragements inferiorly displaced. Fractures through\n the fovea ethmoidalis and both anterior and posterior walls of the frontal\n sinus are also identified. There is a fracture separating the inferior frontal\n and nasal bones. There is orbital emphysema. There is no evidence of muscular\n impingement, and the optic nerves and globes appear normal. The anterior\n clinoids are intact. There is a small hematoma lateral to the left lateral\n rectus muscle.\n\n There is a fracture through the right zygomatic arch and there is a fracture\n of the body of the left zygoma, at the inferolateral aspect of the orbital\n rim.\n\n There are fractures of the pterygoid plates.\n\n Fluid levels are visualized in the sphenoid sinus, frontal and ethmoid air\n cells.\n\n\n Subcutaneous air is seen anterior to the right maxillary sinus and lateral to\n the left maxillary sinus. Mandibles are intact. Bilateral skull fractures are\n also noted invloving the temporal bones.\n\n IMPRESSION: Multiple facial bone and orbital fractures, as described.\n\n (Over)\n\n 5:34 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: S/ , MS, FACIAL SWELLING, BRUISING, ASSESS FOR FRACTURE\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2130-10-25 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 839398, "text": " 5:50 PM\n CTA CHEST W&W/O C &RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST\n CT 150CC NONIONIC CONTRAST\n Reason: S/ , MS, ABDOMINAL APIN, ASSESS FOR INTERNAL INJURY\n Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/ , ms\n REASON FOR THIS EXAMINATION:\n assess for blood\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm WED 10:25 PM\n 2 cm mesenteric enhancing mass. COuld represent a hematoma, although not\n typical for it. Other differential include a mass or lymph node\n WET READ VERSION #1 AZm WED 6:25 PM\n 2 cm mesenteric hematoma\n WET READ VERSION #2 AZm WED 6:29 PM\n 2 cm mesenteric hematoma. T1 post elements fracture\n WET READ VERSION #3 AZm WED 7:59 PM\n 2 cm mesenteric hematoma.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n lung apices through the pubic symphysis. Multiplanar reconstructions were\n obtained for further evaluation of the anatomy and pathology.\n\n CONTRAST: 150 cc of IV Optiray was administered.\n\n CT OF THE CHEST WITH IV CONTRAST: The soft tissue window images reveal no\n significant axillary, mediastinal or hilar lymphadenopathy. The heart,\n pericardium and great vessels are unremarkable. There are no pleural or\n pericardial effusions.\n\n The lung window images reveal bibasilar atelectasis. No lung nodules or\n opacities are visualized. The airways appear patent to the level of segmental\n bronchi bilaterally.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a 1.5 x 2 cm hyperattenuating,\n well-circumscribed area in the mesentery just above the aortic bifurcation. A\n small area of eccentric calcification is noted. It measures 105 Hounsfield\n units. There is no evidence of free fluid. No free air is visualized. A few\n small non-pathologically-enlarged lymph nodes are visualized in the vicinity.\n The largest ones are seen just superior to the pancreatic head and measure 1.5\n and 1.1 cm, respectively.\n\n The liver, gallbladder, spleen, pancreas, adrenals, kidneys appear\n unremarkable. There is some calcification of the abdominal aorta. The aorta\n and its major abdominal branches are patent. The evaluation of bowel is\n incomplete due to lack of oral contrast. However, it grossly appears\n (Over)\n\n 5:50 PM\n CTA CHEST W&W/O C &RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST\n CT 150CC NONIONIC CONTRAST\n Reason: S/ , MS, ABDOMINAL APIN, ASSESS FOR INTERNAL INJURY\n Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n unremarkable.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, seminal vesicles,\n distal ureters appear unremarkable. The pelvic loops of small and large bowel\n appear grossly unremarkable. Some calcification is noted in the prostate\n gland. There is no free air or free fluid. There is no pelvic or inguinal\n lymphadenopathy.\n\n There are no suspicious lytic or blastic lesions in the osseous structures. No\n fractures are visualized. Degenerative changes are seen at the L5-S1\n vertebral levels.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the presence of a\n well-circumscribed rounded hyperattenuating mass in the mesentery.\n\n IMPRESSION: A well-circumscribed hyperattenuating mass in the mesentery. This\n is not typical for a hematoma. However, in the setting of trauma this is a\n consideration. Other differentials include mesenchymal mass or enhancing\n lymph node. Lymphoma can be a consideration.\n\n\n\n KEYWORD: Mesemtery\n\n" }, { "category": "Radiology", "chartdate": "2130-10-30 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 839830, "text": " 10:17 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Position of postoperative reduction of facial fractures. Pl\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p MCA resulting in mid and upper face fractures as well as\n depressed right temporal bone fracture. Pt is now s/p ORIF of facial\n fractures.\n REASON FOR THIS EXAMINATION:\n Position of postoperative reduction of facial fractures. Please complete 3D\n reconstructions.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post facial fractures, please evaluate positioning and\n complete 3D reconstructions.\n\n COMPARISON: CT sinus without contrast of .\n\n TECHNIQUE: Axial noncontrast images were obtained, with additional sagittal\n and coronal reconstructions, as well as 3D snapshot reconstructions.\n\n FINDINGS: There has been interval reduction and stabilization with surgical\n appliances to the lateral and inferior wall of the orbit superfically. There\n has been interval improvement of the alignment of the right zygomatic arch\n fracture, which is now in near-anatomic position. Additionally, the ethmoid\n fractures and orbital wall fractures are now in near-anatomic position. There\n has been no interval change in the fracture deformity of the cribriform plate,\n planum, and skull base.\n\n Multiplanar and 3D reconstructions again identify multiple facial bone\n fractures, as previously described, with no interval change. Again noted are\n fluid levels in the sphenoid, frontal, and ethmoid sinuses with no interval\n change. The mandibles are intact with no evidence of fracture.\n\n IMPRESSION: Interval reduction and improvement in the anatomical positioning\n of the right zygomatic arch fracture, ethmoid fractures, and orbital wall\n fractures. Interval surgical stabilization appliances of the lateral and\n inferior orbital wall superficially. No interval change of the remaining\n fracture/deformities, most notably in the cribriform plate, planum, and skull\n base.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-26 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 839515, "text": " 4:58 PM\n MR CERVICAL SPINE Clip # \n Reason: \\\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p motorcycle accident with multiple face fractures\n REASON FOR THIS EXAMINATION:\n Ligamentous injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post MVA with multiple face fractures. R/O ligamentous\n injury.\n\n MRI OF THE CERVICAL SPINE:\n\n TECHNIQUE: Sagittal short TR, short , TR, long TE, gradient echo and\n STIR imaging was performed through the cervical spine. Axial imaging was\n performed with long TR, long TE, fast spin echo technique. Comparison is made\n to the prior CT scan from .\n\n FINDINGS: Alignment of the cervical spine is normal. The spinal cord appears\n normal in caliber, configuration and signal intensity. There are no areas of\n bone edema detected to suggest acute fractures. There is no evidence of\n ligamentous injury on this MR examination. Please note that the sensitivity of\n the MR for detecting significant ligamentous injury is unknown. There are\n degenerative changes at C5-6 and C6-7 with loss of disc space height and\n osteophyte formation.\n\n Axial images reveal no significant abnormalities from C2 through C4. At C5-6,\n intervertebral osteophyte formation narrows the spinal canal and touches the\n ventral surface of the spinal cord. However, CSF is present surrounding the\n spinal cord. There is moderate bilateral neural foraminal narrowing due to\n uncovertebral osteophyte formation.\n\n At C6-7 small intervertebral osteophytes slightly narrow the spinal canal with\n no encroachment on the spinal cord. The neural foramina appear normal.\n\n Axial images from C7 through upper T2 reveal no significant abnormalities.\n\n IMPRESSION: Mild degenerative disc disease as described above.\n\n No evidence of ligamentous injury. Please note that the sensitivity of the MR\n for detecting ligamentous injury is unknown.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 839831, "text": " 10:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval changes\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M s/p MCA, with mult facial fx, s/p ORIF, L temporal fx & mult intracranial\n bleeds\n REASON FOR THIS EXAMINATION:\n eval interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA with multiple facial fractures, status post ORIF,\n please evaluate for status of fracture alignment and progression of\n intracranial bleeding.\n\n COMPARISON: CT head without contrast of .\n\n FINDINGS: NO interval change in the appearance of the bilateral subdural\n hematomas, subarachnoid hemorrhage, or small amount of intraventricular\n hemorrhage. Again, there is no hydrocephalus, mass effect, or shift of\n normally midline structures. No evidence of more acute hemorrhage is\n identified. The previously seen frontal pneumocephalus has resolved and is\n not visualized on the current exam. Stable appearance of multiple facial\n fractures. Small osteoma seen on the left anterior cranium, not previously\n commented on.\n\n IMPRESSION: Stable appearance of the bilateral subdural and subarachnoid\n hemorrhages, with interval resorption of the frontal pneumocephalus. No\n interval progression of mass effect or shift of normally midline structures.\n Stable appearance of multiple facial fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-25 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 839391, "text": " 5:20 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVC\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma, status-post motor vehicle collision.\n\n CHEST, AP SUPINE VIEW: The heart is normal in size. There is apparent\n widening of the mediastinum, which may be due to supine positioning. Low lung\n volumes are present bilaterally. There are no pleural effusions, focal\n consolidations, or pneumothorax demonstrated. There is no overt evidence of\n pulmonary vascular engorgement. An old left posterior 3rd rib fracture is\n present.\n\n PELVIS, AP SUPINE VIEW: No fracture, dislocation, or degenerative changes are\n identified. Pubic symphysis, both hips, and sacroiliac joints appear\n preserved. Sacral struts are intact. Overlying trauma board limits complete\n evaluation in the pelvis. No soft tissue calcifications or masses are\n present.\n\n IMPRESSION\n\n 1. Apparent widening of the mediastinum, likely secondary to supine\n positioning. If there is any clinical concern for traumatic injury to the\n mediastinum, CT of the chest can be performed for further evaluation.\n Otherwise, no acute cardiopulmonary process.\n\n 2. No fracture or dislocation within the pelvis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 839495, "text": " 2:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check line placement\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M facial fx s/p L subclavian\n\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P left subclavian central venous line placement.\n\n PORTABLE AP CHEST: Comparison is made with . Tracheostomy\n tube is unchanged in position. There is a new left subclavian central venous\n line with a tip in the proximal SVC. No pneumothorax is seen. The NG tube\n tip is visualized, within the gastric body. There is stable congestive heart\n failure and patchy areas of opacity in both lower lobes, likely secondary to\n atelectasis. Pneumonia cannot be exclued. The degree of widening of the\n superior mediastinal contours is improved, consistent with positionally\n dilated vascular structures, now appearing normal in a semi-upright position.\n Osseous structures are unchanged.\n\n IMPRESSION: Successful left subclavian central venous line placement. Tip is\n proximal SVC. No pneumothorax. NG tube tip below diaphragm. Unchanged\n appearance of heart and lungs. Improved superior mediastinal contours.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 839419, "text": " 2:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: repeat film at 12 hours (about 3-4am on ). please do TH\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50M s/p motorcycle accident, with R epidural bleed & temporal fracture\n REASON FOR THIS EXAMINATION:\n repeat film at 12 hours (about 3-4am on ). please do THIN CUTS THROUGH R\n TEMPORAL BONE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Right epidural bleed and temporal fracture.\n\n Noncontrast head CT with additional axial thin section images through the\n skull base.\n\n Exam compared to prior study of .\n\n FINDINGS: Some increased density associated with the superior cerebral sulci\n especially on the left is slightly less evident than formly and is certainly\n not increased it is still present however. There is a new focus of increased\n density in the interpeduncular cistern probably representing some\n redistribution of subarachnoid blood. The ventricles are unchanged in\n dimension. The extraaxial fluid collections anterior to the temporal lobes are\n unchanged. There is still is pneumocephalus visualized in the right middle\n cranial fossa. The multiple squamosal temporal bone fractures are again noted\n together with a transverse fracture of the petrous portion of the right\n temporal bone. There may be slight separation of the malleo-incal joint\n suggesting possible disruption. There is some increased fluid in the right\n mastoid and multiple facial fractures are again identified.\n\n IMPRESSION: Persistent extraaxial and subrachnoid hemorrhage as described.\n Some blood is seen in the convexity subarachnoid space as well as in the\n interpeduncular cistern. A right transverse petrous temporal fracture is noted\n with perhaps malleo-incal disruption.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-26 00:00:00.000", "description": "T-SPINE", "row_id": 839420, "text": " 3:05 AM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: r/o fx/dislocation\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n r/o fx/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P MCC.\n\n THORACIC & LUMBAR SPINE AP & LATERAL: NG tube projects over the left upper\n quadrant. ETT is at the thoracic inlet. The vertebral body height, alignment\n are within normal limits. No evidence of compression fracture or\n spondylolisthesis. There are multiple levels of degenerative changes\n throughout the thoracic and lumbar spine. There is loss of joint space at\n L5/S1 with a vacuum disc.\n\n IMPRESSION:\n\n 1. No evidence of acute injury.\n\n 2. Thoracic and lumbar spondylosis.\n\n" }, { "category": "Radiology", "chartdate": "2130-11-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 840110, "text": " 1:09 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p fall in room, hit head, small nose lac. no LOC\n Admitting Diagnosis: TRAUMA;SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man s/p MCA resulting in mid and upper face fractures as well as\n depressed right temporal bone fracture. Pt is now s/p ORIF of facial\n fractures.\n REASON FOR THIS EXAMINATION:\n s/p fall in room, hit head, small nose lac. no LOC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of MVA with intracranial hemorrhage and multiple facial\n fractures, recently fell out of bed, hit head and nose, evaluate for new\n bleed.\n\n COMPARISONS: Non-contrast head CT from .\n\n FINDINGS: There has been no interval change in the appearance of the small\n bilateral subdural hematomas, and left sided subarachnoid hemorrhage. No new\n intracranial hemorrhage is identified. Stable appearance of old fractures with\n no new fracture identified. Again, no evidence of shift of normally midline\n structures or progressive hydrocephalus.\n\n IMPRESSION: No new intracranial hemorrhage. Stable appearance of multiple\n facial fractures. Stable appearance of small subdural and subarachnoid\n hemorrhages. No change from previous exam of .\n\n" }, { "category": "ECG", "chartdate": "2130-11-08 00:00:00.000", "description": "Report", "row_id": 184680, "text": "Sinus rhythm\nSince pervious tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2130-11-02 00:00:00.000", "description": "Report", "row_id": 184681, "text": "Sinus rhythm\nNormal ECG\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-29 00:00:00.000", "description": "Report", "row_id": 1441480, "text": "TSICU NPN 7A-7P:\n\nEVENTS: OFF VENT AND ON TRACH COLLAR MASK THROUGHOUT THE DAY. PT, PER FAMILY, HAS PERIODS OF SLEEP APNEA AT HOME PRIOR TO ADMISSION. THROUGHOUT THE DAY, RR 6-18. OCCASIONALLY VERY EVEN AND UNLABORED. FAMILY IN AND OUT. PT DROWSY BUT APPROPRIATE.\n\nNEURO: ALERT AT TIMES, TRIES TO OPEN EYS, BOTTOM LIDS SEWN TO EYEBROW. PT NODS THAT HE UNDERSTANDS THIS. CONTINUALLY ORIENTING HIM TO PLACE AND TIME AND EVENT. MAE WELL. ASSISTS WITH TURNING. PERL 3MM (CHECKED X1). FENTANYL FOR PAIN, REQUIRES ENCOURAGEMENT TO ACCEPT PAIN MEDS. BRIEF PERIOD OF RESTLESSNESS/ANXIETY. SETTLED WITH PAIN MEDS, REPOSITIONING AND REASSURANCE. SOFT WRIST RESTRAINTS IN PLACE FOR PROTECTION OF LINES, PT DOES TRY TO PULL AT THEM. FOLLOWS COMMANDS AND NODS IN ANSWER TO QUESTIONS.\n\nCV: SR WITH NO ECTOPY. BP STABLE BY CUFF. PALP DP AND PT PULSES BILAT. GEN EDEMA.\n\nRESP: ON TRACH MASK. TOLERATING WELL WITH SATS 98-100%. DENIES SHORTNESS OF BREATH. LUNG SOUNDS CLEAR, SLIGHTLY DIM IN BASES AT TIMES. RAISING SMALL AMOUNTS THICK WHITE SPUTUM, GOOD COUGH EFFORT AND RARE TRACH SUCTIONING REQUIRED.\n\nGI: ABD. SOFT, ROUND, NONTENDER. + BOWEL SOUNDS. DENIES NAUSEA. ADVANCING TUBE FEEDS PROMOTE WITH FIBER AS TOLERATED. MINIMAL RESIDUALS. NPO.\n\nGU: FOLEY WITH CLEAR YELLOW URINE. IVF AT 75/HOUR.\n\nENDO: COVERAGE WITH RISS. ONGOING TAPER OF DECADRON.\n\nHEME, ID: NO ISSUES.\n\nSKIN: FACE ECCHYMOTIC AND SLIGHTLY SWOLLEN, ESP. AROUND EYES. SUTURES IN PLACE TO HOLD LOWER LID UP. LEFT HAND XRAYED TODAY TO R/O FX. PRELIM READ WITH NO FX. HAND IS SLIGHTLY MORE SWOLLEN THAN RIGHT HAND AND CRUNCHING NOTED WITH MOVEMENT.\n\nSOCIAL: WIFE AND DAUGHTER IN AND UPDATED. MULTIPLE FRIENDS IN PER WIFE'S REQUEST. VISITORS SUPPORTIVE AND COOPERATIVE.\n\nPLAN: CONTINUE WITH PULM TOILET. ? SWALLOW EVAL AND REMOVAL OF ENTERAL FEEDS. ONGOING PAIN ASSESSMENTS AND MEDICATION AS NEEDED. INCREASE ACTIVITY AS TOLERATED. ONGOING COMMUNICATION WITH FAMILY. ? PLANS TO TRANSFER TO SURGICAL FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-30 00:00:00.000", "description": "Report", "row_id": 1441481, "text": "ROS:\n\nNeuro: Alert, follows commands, nods head and mouths words. As shift progressed swelling decreased in face and has been able to open both eyes. Hand grasps strong and =, dorsi plantor/flexion strong and =. Requiring fentanyl 50 mcg prn for pain. Dilantin 200 mg q 8hr prophylacticly.\n\nResp: Trached and on trach mask 60% humidified o2. Lungsound clear. Coughs moderate to large amt of thick light yellow sputum. No resp distress noted, = rise and fall of chest. Sats 100%.\n\nCV: SB->RSR w/o ectopy. S1S2. VSS, see flow record for details. Peripheral pulses palpable w/ease. P boots and heparin prophylacticly. Generalized puffyness.\n\nGI: oral sump w/promote w/fiber infusing at goal (80cc) w/minimal residuals. Abd round soft w/active bowel sounds. Passing flatus often. H2 blocker prophylacticly.\n\nGU: Foley patent draing clowdy yellow urine in QS\n\nEndo: FSG covered w/RSSI\n\nLabs: All AM labs pending at this time.\n\nPlan: Transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-28 00:00:00.000", "description": "Report", "row_id": 1441476, "text": "NPN 1900-0700\n\n Pt sleepy most of shift. Denied pain and refusing pain med when offered. Last recieved Fent at 1900. More alert at 0500. Ox3, able to talk with trach cuff deflated. MAEs well, FCs consistently. PERLA. Bilateral black eyes.\n\nRESP- Trach cuff down all shift, on trach collar. Able to effectively cough up secretions, trach care done several times. Sx with cath x 2 for scant secretions. Open skin around trach red and no drainage. Lungs coarse.\n\nCV- SR no ectopy. Aline damened and very postional. Unable to draw , MD aware no ABGs done. Afebrile, WBCs up from 18 to 23.2. Skin w/d. Good PPx4. Lytes repleted. FSBS < 120.\n\nGI/GU- Abd round, soft, +BS. Pt pulled out NGT on previous shift. Adeq UO.\n\nPlan- OR today for facial fractures, time not scheduled. Anesthesia consented pt.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-28 00:00:00.000", "description": "Report", "row_id": 1441477, "text": "Nursing Note:\nREVIEW OF SYSTEMS:\n\nCV: Hemodynamic status stable, hr=63-76 nsr, no ectopy, ext. + dp bil, feet cool, bp=120/65-135/69\n\nRESP: Maintained on trach mask, coughing up thick yellow secretions, sat=100%. Trach site with large verticle incision. Cuff down throughout the day.\n\nGI: NPO for OR iv fluid infusing as ordered\n\nGU: Foley to gravity, u/o=160-180 q 1hr, clear yellow urine\n\nMENTATION: Large hematoma left orbital area, perl, 3mm bil, oriented to name, time, not to place, recognizes wife. Sleeping in naps throughout the day. Speaking in short phrases. Upper ext. +5/+5 bil, lower ext. +5/+5. + cough, Head cat scan done. No csf drainage noted from nose.\n\nID: Afebrile\n\nENDO: BS as per sl. scale\n\nSOCIAL: Wife in to visit, stayed with patient until call to OR.\n\nPLAN: Continue with pul. toilet, replete lytes, insulin as per sl. scale, monitor v/s, continue to provide support to family.\n\nPt. to OR at 2pm for repair of facial fx.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-28 00:00:00.000", "description": "Report", "row_id": 1441478, "text": "Pt is s/p repair of facial trauma after cycling accident. Plan for overnight is to continue on propophol and support at current vent settings overnight, re-assess in morning rounds.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-29 00:00:00.000", "description": "Report", "row_id": 1441479, "text": "S/P ORIF of Leforte III\n\nPt awakened off Propofol after 30 minutes. Moves all extremities, follows commands. Receiving Fentanyl prn for facial pain. Dilantin as ordered.\n\nVSS. IVF at 75cc/hr. Electrolytes normal. HCT 34.9.\n\nVent weaned to PSV5/PEEP 5 once sedation lightened. RR 15, spont. tidal volume 860. Suctioned for small amt. white sputum. Breath sounds clear, sats 100%. Trach site clean.\n\nPromote tube feedings started via OGT with low residuals. Abd. soft, bowel sounds active. No stool.\n\nUrine output adequate.\n\nPt's lower eyelid sutured to his forehead. Ice applied to eye area throughout entire night. Eye area is ecchymotic but not swollen. No drainage from nares. Small amt. serosanginous drainage from right eye. Left hand appeared weaker than right with \"crunching feeling\" in thumb-xray ordered. Skin on back intact. Pt is afebrile, WBC 18.5, remains on Ceftriaxone.\n\nPt's family visited after surgery and then went home. They appear to understand plan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-26 00:00:00.000", "description": "Report", "row_id": 1441471, "text": "TSICU Nursing Progress Note\nTraveled to MRI for C-spine series -- well tolerated.\n\nNeuro - Sedated on propofol. Pupils equal and reactive. Dilated by optho at 1400. Follows commands when awakened. Moves all extremities, equal and strong. Strong cough. C-collar in place. TLS cleared. CSF leaking from nose with coughing/gagging. Sample sent for glucose, B2 transferrin. Neurosurg will give leak a few days to stop on its own, will place lumbar drain if it continues.\n\nCV - Hemodynamically stable. SR without ectopy. Strong peripheral pulses.\n\nResp - Tolerating vent settings on propofol. #7 portex trach in place. Suctioned for small amounts of blood tinged sputum. Strong cough.\n\nGI - OGT to constant wall suction. Draining small amounts of bilious fluid. + BS, no BM.\n\nGU - Adequate amounts of clear yellow urine via foley.\n\nSkin - Facial abrasions OTA. Abrasion on back OTA. Skin otherwise intact.\n\nPain - Denies pain when awakened. Treated presumtively for procedures.\n\nA - Hemodynamically and neurologically stable post MCC.\n\nP - Continue to monitor hemodynamic status. Support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-27 00:00:00.000", "description": "Report", "row_id": 1441472, "text": "ASSESSMENT AS NOTED\n ORAL SURGERY TEAM CAME IN LAST NIGHT TO EXAMIN THE PATIENT AND TALKED TO HIS WIFE VIA THE PHONE ABOUT TIMING OF HIS SURGERY. THEY ARE PLANNING TO OPERATE ON THIS SUTURDAY OR NEXT MONDAY\n\nNEURO: AWAKE AND COOPERATINE WHEN OFF PROPOFOL, WOKEN UP Q4H, FOLLOWS ALL COMMANDS, MAE STROMG, PERL AND RECOVERED AFTER EYE EXAM DILATATION\nON DILANTIN AND DEXAMETAZON STILL, STILL OOZING CSF FROM R. NOSTRIL WHEN IN EXERTION OR COUGHING:NEURO TEAM IS AWERE. CER COLLAR IS ON\n\nRES: REMAINS VENTED ON 40%,5PS, 5PEEP WITH PCO234, MAINTAINS SO2>97,\nLESSSECRETIONS IN TRACH, NPC, LS COARSE/ DIM\n\nCV: STABLE, IN NSR, NO ECTOPY\n\nGU: BRISK U/O 100-300/H CLEAR YELLOW,\n\nLABS: INR DOWN TO 1.1, HCT 36\n\nSKIN: TRACH CARE DONE-LESS SECRETIONS BUT STILL SCANT AMNT OF RED S/S\nDRAINAGE. FACE IS WITH LESS EDEMA AND BRUISING.\n\nGI: T.FEEDING WAS STARTED AND ADVANCED TO 30CC/H WITH SMALL RESIDUALS\n\nA: POST MVA, ALTERATION IN AIRWAY/OXYGENATION DUE TO FACIAL FX\n\nP: FULL SUPPORT, MONITOR NEURO, RES\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-27 00:00:00.000", "description": "Report", "row_id": 1441473, "text": "Respiratory Care\nPt remained trached and ventilated o simv with no remarkable changes overnight. ABGs with slight resp alkalosis and good oxygenation. Pt not overbreathing vent rate.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-27 00:00:00.000", "description": "Report", "row_id": 1441474, "text": "Resp. care note - Pt. remaines trached, weaned to 50% TM, tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-27 00:00:00.000", "description": "Report", "row_id": 1441475, "text": "NPN T/SICU\nREVIEW OF SYSTEMS:\n\n PT ALERT AND ORIENTED X3,MAE.FAMILY IN TO VISIT.C-SPINE CLEARED BY MRI,COLLOR REMOVED.FENTYNAL PRN FOR PAIN WITH GOOD EFFECT.MOUTHING WORDS APPROPRIATLY.CONTINUES TO HAVE CLEAR CSF DRAINING FROM NOSE.\n\n PT IN SR,BP STABLE.LT SUBCLAVIAN CENTRAL LINE IN PLACE.IVF AT 75CC/HR. ALINE INTACT.\n\nRESP- WEANED TO TRACH COLLOR 50%,TOLERATED WELL WITH CUFF DONE.STRONG PRODUCTIVE COUGH.\n\nGI- TUBE FEEDS ADVANCING WELL.NO BM,BS PRESENT.\n\nGU- UO GOOD VIA FOLEY.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-26 00:00:00.000", "description": "Report", "row_id": 1441467, "text": "ADM NOTE\n\n ASSESSMENT AS NOTED\n\nPT WAS ADMITTED LAST NIGHT FROM OR P/OP TRACHEOSTOMY\n\nINVOLVED IN MVA ON THE BIKE , WEARING HELMET. PT IS A POLICEMEN AND WAS RIDING HOME FROM WORK.\n WAS COMBATIVE ON THE SCEEN AND IN THE AND NEEDED TO BE SEDATED. WAS TALKING TO STAFF IN ER AND BECAME MORE OBTANDED--> HEAD CT(SMALL SDH AND SAH +TEMPORAL FX + MULTIPLE FACE FR LAFORT#3 FX)\nABD/PELVIC CT( MASS 1X2CM IN MESSENTERIC AREA ? BLEED VS BENIGN TU)\nWAS TRACHED B/C OF FACE FRUCTURES AND AIRWAY PROTECTION\nENT IS WORKING ON TRACH AND R. EAR (BLEEDING)\nPLASTICS AND ORAL SURGERY ON FACIAL FXS: WILL BE TAKEN TO OR LATER OR IN COMMING DAYS(FAMILY TALKED TO ORAL SURGERY AND AWERE)\n\n RES: ON VENT NOW 40%, 20 X 5 X5, MAINTAINS SO2>98, SMALLAMNT BLOODY SECRETIONS IN TRACH(#7 PORTEX). LS CLEAR/COARSE, PT IS A SMOKER 2PPD\nSEE ABG IN CAREVUE. PCXR WAS DONE 2200 LAST NIGHT POST OP.\n\n CV: BP STABLE, IN NSR, HYPERDYNAMIC WHILE AWAKE. BP BY A/LINE\n\n NEURO: AWAKE WHEN OFF PROPOFOL AND RESTLESS, STRONG ALL EXTREMITIES, PURPUSFUL, FOLLOWS SIMPLE COMMANDS. FOLLOW UP HEAD CT (4AM) WAS UNCHENGED.WAS CHECKED BY NEUROSURGERY RESIDENT LAST NIGHT. PERL-SLAGGISH 2MM. CERV COLLAR IS ON AND LOGROLL MAINTAINED\nON DILANTIN(GOT LOAD IN ER) AND DEXAMETAZONE\nCON'T OOZING FROM THE NOSE(NEUROSURGERY AWERE)? CSF LEAK???\n\nLABS: MAG GIVEN FOR 1.7, CA WAS GIVEN FOR 1.08, HCT STABLE, BS IS BY RISS\n\n GU: GOOD U/O CLEAR YELLOW\n\n GI: OGT WAS PUT IN THE UNIT TO LWS DRAINED 100CC FIRST BLOODY AND LATER BROWN SECRETIONS.\n\n SKIN: SMALL ABRASION ON R. MIDBACK, BRUISING AND EDEMA IN BOTH PERIORBITAL AND EYES AREA. I WAS ABLE TO RETRACT BOTH EYELIDS.\n TRACH WOUND IS PACKED WITH IODOFORM TAPE AND COVERED WITH DSD.\n\nSOCIAL: FAMILY(WIFE) WAS IN AND TALKED TO NEURO, ORAL SURGERY AND\n TRAUMA. PT'S CO-WORKERS ALSO CAME IN(COPS) TO VISIT.\n\n A: ALTERATION IN RES, NEURO, MUSCULAR /SKELETAL FUNCTIONS\n P: MONITOR NEURO, RES, FULL SUPORT\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-26 00:00:00.000", "description": "Report", "row_id": 1441468, "text": "Respiratory Care\nPt is s/p mva with mult facial fractures. 7.0 Portex trach in place. Suctioned for some blood tinged thick secretions. Breath sounds are clear. Vent settings- 700 x 20 Simv 40% +. Had weaned tidal volume down due to resp alkalosis. O2 sat 98-100.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-26 00:00:00.000", "description": "Report", "row_id": 1441469, "text": "P/S : NEUROSURG. IS IN AND PLANING TO CORRECT INR(1.6) AND THINKING TO PUT LUMBUR DRAIN TO FIX NASAL CSF DRIP.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-26 00:00:00.000", "description": "Report", "row_id": 1441470, "text": "\nPT MAINTAINED ON SIMV-PSV VENTILATION AT 40%. VITALS STABLE, AFEBRILE. SX. FOR SM AMTS OF BLD TINGED. B.S. MOSTLY CLEAR. LAST ABG SHOWED AN ALKALOSIS WITH GOOD OXYGENATION. PT SEDATED BUT MENTAL STATUS IS GOOD WHEN ALLOWED TO WAKE UP. NO SCHEDULED TRAVELING FOR TODAY. FAMILY IN VISITING. PLAN IS TO CONT ON SAME SETTINGS WITH O.R. TIME SHEDULED FOR THE NEAR FUTURE.\n" } ]

[ { "category": "Radiology", "chartdate": "2164-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230591, "text": " 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with fever, AMS\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 63-year-old woman with fever and altered mental status.\n Evaluate for pneumonia.\n\n COMPARISON: Chest radiograph and .\n\n FINDINGS: A frontal semi-upright view of the chest was obtained portably.\n Increased perihilar opacities and Kerley B lines are compatible with pulmonary\n edema. The cardiac silhouette is enlarged, similar to prior studies. The\n right costophrenic sulcus is not well seen, possibly due to a small right\n pleural effusion. There is no left pleural effusion. No pneumothorax.\n Aortic knob calcifications are again seen.\n\n Hardware in the left humeral head, incompletely evaluated on this study. The\n left humeral head is not seated in the glenohumeral joint and appears more\n displaced than on and definitely more displaced than on .\n Some of the difference may be due to differences in patient position.\n\n IMPRESSION:\n 1. Moderate pulmonary edema with possible small right pleural effusion.\n Consider repeat radiograph after diuresis to evaluate for underlying\n pneumonia.\n 2. Increased left shoulder dislocation/displacement since and\n , which may in part be due to technique. Dedicated shoulder\n radiographs could be obtained if clinically indicated.\n\n Discussed with Dr. by phone at 8:10pm .\n\n" }, { "category": "Radiology", "chartdate": "2164-04-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1230594, "text": " 9:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: SDH or other acute process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with markedly altered mental status\n REASON FOR THIS EXAMINATION:\n SDH or other acute process?\n CONTRAINDICATIONS for IV CONTRAST:\n cr 1.7\n ______________________________________________________________________________\n WET READ: EHAb SUN 9:43 PM\n 1. No CT evidence for acute intracranial process.\n 2. Partial opacification of the ethmoid air cells bilaterally with aeroselized\n secretions on the left, new since , suggesting acute sinusitis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with altered mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast. Coronal and sagittal reformatted images were reviewed.\n\n FINDINGS: There is no evidence for acute intracranial hemorrhage, large mass,\n mass effect, edema, or hydrocephalus. There is preservation of -white\n differentiation. The basal cisterns appear patent. White matter\n hypodensities are likely secondary to sequela of chronic small vessel ischemic\n disease and appears similar compared to prior. Note is made of a 5-mm round\n soft tissue density in the left nuchal subcutaneous fat (2;7), likely\n representing a sebaceous cyst. Visualized bones are within normal limits.\n There is new partial opacification of the ethmoid air cells bilaterally with\n aeroselized secrections; the remainder of the visualized portions of the\n paranasal sinuses and mastoid air cells is well aerated.\n\n IMPRESSION:\n 1. No CT evidence for acute intracranial process.\n 2. Partial opacification of the ethmoid air cells bilaterally, which is new\n compared to , with aerosolized secretions in the left ethmoid air\n cells, could relate to possibility of acute sinusitis.\n\n" }, { "category": "Radiology", "chartdate": "2164-04-08 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1230596, "text": " 11:10 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 63F with fever, AMS, c/o RLQ Clinical Question: diverticulitis or\n other infectious source?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n CONTRAINDICATIONS for IV CONTRAST:\n\n ______________________________________________________________________________\n WET READ: EHAb MON 1:10 AM\n 1. Small consolidation at right lung base with small right pleural effusion,\n which could represent infection.\n 2. Tiny focus of hyperdensity in the stomach likely represents ingested\n material, but acute bleeding cannot be excluding. Clinical correlation is\n recommended.\n 3. No acute intra-abdominal or pelvic pathology detected; normal appendix, two\n cecal diverticula without evidence for inflammation.\n 4. Right lateral abdominal wall with area of assymetric expansion of the\n subcutaneous fat with internal soft tissue densities and minimal overlying\n skin thickening; clinical correlation for history of trauma and physical exam\n are recommended.\n 5. Large amount of air in the bladder, which could be related to\n instrumentation.\n 6. Small amount of pericardial fluid.\n\n These findings and recommendations were discussed with Dr. by phone at\n 1:09 a.m. on .\n WET READ VERSION #1\n WET READ VERSION #2 EHAb MON 1:04 AM\n 1. Small consolidation at right lung base with small right pleural effusion,\n which could represent infection.\n 2. Small amount of pericardial fluid.\n 3. No acute intra-abdominal or pelvic pathology detected; normal appendix, two\n cecal diverticula without evidence for inflammation.\n 4. Large amount of air in the bladder, which could be related to\n instrumentation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with fever, altered mental status, and\n abdominal pain.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the abdomen and pelvis were acquired\n without intravenous or oral contrast. Coronal and sagittal reformatted images\n were reviewed.\n\n FINDINGS:\n\n (Over)\n\n 11:10 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ABDOMEN: There is a small right basilar pulmonary consolidation with adjacent\n small pleural effusion. The visualized portion of the left lung base\n demonstrates minimal dependent atelectasis. There is a small amount of\n pericardial fluid. Coronary calcifications are incompletely imaged.\n\n Within the limitations of a non-contrast enhanced examination, the liver,\n gallbladder, spleen, atrophic pancreas, adrenal glands, kidneys, and\n visualized loops of small bowel are within normal limits. Few cecal\n diverticula do not demonstrate evidence for inflammation; the colon is\n otherwise unremarkable. The appendix is normal. There is a small focus of\n hyperdensity within the stomach (2:17) which likely represents ingested\n material. No ascites or free intraperitoneal air is detected. Extensive\n vascular calcifications are noted.\n\n PELVIS: There is a large amount of air in the bladder, which may be related\n to recent instrumentation; a Foley catheter is seen within the bladder. The\n uterus and adnexa are within normal limits other than extensive adnexal\n vascular calcifications.\n\n No lymph nodes which meet CT criteria for pathologic enlargement are detected.\n\n There is asymmetric expansion of the subcutaneous fat in the right lateral mid\n anterior abdominal wall with new intertwining soft tissue density and mild\n overlying skin thickening.\n\n Healing fracture of the left ilium is again noted. Severe degenerative\n disease at L5-S1 is noted. No concerning lytic or sclerotic osseous lesions\n are detected.\n\n IMPRESSION:\n\n 1. Right lower lobe consolidation with adjacent small effusion, concerning\n for pneumonia.\n\n 2. No acute intra-abdominal or pelvic pathology detected; normal appendix and\n cecal diverticula without evidence for inflammation.\n\n 3. Right lateral abdominal wall with assymetric expansion of the subcutaneous\n fat; internal soft tissue densities and minimal overlying skin thickening are\n new since . Differential diagnosis includes lipoma and less likely\n liposarcoma. Clinical correlation is recommended.\n\n 4. Large amount of air in the bladder, which could be related to\n instrumentation.\n\n 5. Small amount of pericardial fluid.\n (Over)\n\n 11:10 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n These findings and recommendations were discussed with Dr. by\n Dr. by telephone at 1:09 a.m. on .\n\n" }, { "category": "ECG", "chartdate": "2164-04-09 00:00:00.000", "description": "Report", "row_id": 128132, "text": "Sinus rhythm. Non-specific lateral ST segment changes. Compared to the\nprevious tracing the findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2164-04-08 00:00:00.000", "description": "Report", "row_id": 128133, "text": "Sinus rhythm. Mild non-specific lateral ST segment changes. Compared to the\nprevious tracing the findings are similar.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2164-04-10 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 1230824, "text": " 2:21 PM\n ART EXT (REST ONLY) Clip # \n Reason: eval of perfusion to LLE\n Admitting Diagnosis: ALTERED MENTAL STATUS;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63F w/ DM, HTN, recent left great toe injury c/b left great toe osteomyelitis\n s/p OR debridement x2 and distal SFA stenting with course complicated by poor\n wound healing, , acute on chronic systolic CHF presents from rehab with AMS.\n\n REASON FOR THIS EXAMINATION:\n eval of perfusion to LLE\n ______________________________________________________________________________\n FINAL REPORT\n NON-INVASIVE ARTERIAL STUDY AT REST\n\n INDICATION: 63-year-old female patient with recent great toe injury, status\n post OR debridement and distal SFA stenting.\n\n TECHNIQUE: Doppler waveforms, pulse volume recordings, and segmental blood\n pressures were obtained in the lower extremities bilaterally.\n\n FINDINGS: There is a monophasic Doppler waveform in the bilateral common\n femoral, superficial femoral, popliteal, posterior tibial, and dorsalis pedis\n arteries. The ABI index on the right is 0.81 and on the left is 0.81. The\n pulse volume recordings are symmetrical bilaterally.\n\n IMPRESSION: Findings consistent with moderate inflow aorto-iliac arterial\n insufficiency.\n\n" }, { "category": "Radiology", "chartdate": "2164-04-10 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 1230828, "text": " 2:59 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: residual L great toe osteo?\n Admitting Diagnosis: ALTERED MENTAL STATUS;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63F w/ DM, HTN, recent left great toe injury c/b left great toe osteomyelitis\n s/p OR debridement x2 and distal SFA stenting with course complicated by poor\n wound healing, , acute on chronic systolic CHF presents from rehab with AMS.\n\n REASON FOR THIS EXAMINATION:\n residual L great toe osteo?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old female with diabetes, hypertension and left great toe\n injury status post OR debridement.\n\n COMPARISON: .\n\n FINDINGS: Three views of the left foot demonstrate similar appearance of\n distal first ray resection to the level of distal proximal phalanx. Joint\n spaces are preserved. No new fracture. Vascular calcifications are noted.\n\n" }, { "category": "Radiology", "chartdate": "2164-04-09 00:00:00.000", "description": "L ART DUP EXT LO UNI;F/U LEFT", "row_id": 1230697, "text": " 3:57 PM\n ART DUP EXT LO UNI;F/U LEFT Clip # \n Reason: evaluate patency of left SFA\n Admitting Diagnosis: ALTERED MENTAL STATUS;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with prior SFA surgery\n REASON FOR THIS EXAMINATION:\n evaluate patency of left SFA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old lady with prior superficial femoral artery surgery.\n Test requested to assess left superficial femoral artery patency.\n\n TECHNIQUE: Evaluation of the left common femoral, superficial femoral, and\n popliteal arteries was performed with grayscale, color and spectral Doppler\n ultrasound.\n\n FINDINGS: Calcified mural plaque was seen in the common femoral, superficial\n femoral, and popliteal arteries. Thesed three arteries are patent; however,\n they demonstrate monophasic Doppler waveforms, which is a sign of arterial\n disease/distal ischemia. The peak systolic velocity in the left common\n femoral artery was 156 cm/sec. Peak systolic velocities within the left\n superficial femoral artery ranged between 86 and 285 cm/sec. Peak systolic\n velocities in the left popliteal artery ranged between 68 and 73 cm/sec.\n\n COMPARISON: Findings are consistent with the noninvasive arterial study\n performed on .\n\n IMPRESSION: Patent left common femoral, superficial femoral, and popliteal\n arteries. They present with monophasic Doppler waveforms which is a sign of\n arterial disease/distal ischemia. No evidence of critical stenosis within the\n arteries studied.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-04-12 00:00:00.000", "description": "R KNEE (AP, LAT & OBLIQUE) RIGHT", "row_id": 953950, "text": " 2:42 PM\n PELVIS (AP ONLY); KNEE (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: please evaluate for fracture\n Admitting Diagnosis: FAILURE TO THRIVE;RENAL CELL CARCINOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with with renal cell CA, lung/hip mets, admitted with hip pain,\n pathological fracture.\n REASON FOR THIS EXAMINATION:\n please evaluate for fracture\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, TWO VIEWS RIGHT FEMUR, AT 14:12 HOURS.\n\n HISTORY: Renal cell carcinoma with known lung and hip metastases.\n\n COMPARISON: Femur from .\n\n FINDINGS: As noted on yesterday's examination there is a 9 cm ovoid lytic\n lesion which has expanded and eroded the lateral margin of the proximal\n femoral diaphysis. Medially there is a new pathologic fracture that had\n developed since the prior examination dated . There is an\n indwelling gamma nail which is fully evaluated on this examination and\n demonstrates no radiographic evidence of loosening. The alignment remains\n intact. The knee joint is appropriately aligned. There is a small joint\n effusion. A small non-aggressive sclerotic lesion is central within the\n medial femoral condyle.\n\n IMPRESSION: No significant interval change since yesterday's study in the\n pathologic fracture of the proximal femur. Alignment has been maintained by\n an indwelling gamma nail which has not changed in course or position.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-15 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 954258, "text": " 10:22 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: Renal cell cancer staging. Please assess chest/abd/pelvis t\n Admitting Diagnosis: FAILURE TO THRIVE;RENAL CELL CARCINOMA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with metastatic renal cell cancer, pathologic R femur fracture\n REASON FOR THIS EXAMINATION:\n Renal cell cancer staging. Please assess chest/abd/pelvis to see other foci of\n renal cell cancer.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n INDICATION: 69-year-old man with metastatic renal carcinoma, pathologic right\n femur fracture. For renal cell carcinoma staging.\n\n COMPARISON: CT torso and CT chest .\n\n TECHNIQUE: MDCT axial images of chest, abdomen, and pelvis were obtained\n following administration of intravenous contrast. Pre-contrast axial images\n of the abdomen were also obtained, as well as delayed images of the kidneys.\n Coronal and sagittal reformatted images were obtained.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: Again seen enhancing right paratracheal\n mass, measuring 59 x 45 mm, compared to 51 x 39 mm previously. The right\n hilar enhancing lymphadenopathy measures 31 x 26 mm, compared to 28 x 25 mm\n previously. A subcarinal lymph node measures 16 x 9 mm, compared to 13 x 5 mm\n previously. Left hilar lymphatic nodes have also increased in size.\n\n In lung windows, there has been interval development of peripheral discoid\n areas of opacities, probably representing atelectasis, however, not entirely\n dependent. In dependent areas, there are areas of septal thickening. Multiple\n sub-4 mm nodules are stable. The central airways are patent to the segmental\n levels bilaterally.\n\n ABDOMEN: The patient is status post right nephrectomy. There are multiple\n surgical clips surrounding the left kidney. Again noted 2-cm exophytic left\n renal cyst. There is a 2.7-cm hypoenhancing lesion in the mid pole of the\n left kidney, not described on the previous studies. It was, however, present\n in , and has decreased in size from to and\n increased from 18 mm in to 27 mm in . There are other\n tiny sub-5 mm hypodensities in the left kidney, too small to definitely\n characterize. 2-cm exophytic simple cyst arising from the mid pole of the\n left kidney is stable in size. The adrenal glands are not visualized, probably\n surgically absent. Liver, gallbladder, spleen, pancreas, and visualized\n portion of the large and small bowel are within normal limits. Again noted\n small retroperitoneal lymphatic nodes, not significantly changed from previous\n examination. There is no free fluid and no free air in the abdomen.\n\n (Over)\n\n 10:22 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: Renal cell cancer staging. Please assess chest/abd/pelvis t\n Admitting Diagnosis: FAILURE TO THRIVE;RENAL CELL CARCINOMA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITH INTRAVENOUS CONTRAST: The bladder, prostate are unremarkable.\n The rectum is distended with stool. There is no pelvic or inguinal\n lymphadenopathy. There is no free fluid in the pelvis.\n\n BONE WINDOWS: Redemonstrated is a large lytic lesion in the right proximal\n femur, status post gamma nail fixation. No new osseous lesions are noted. The\n soft tissue, replacing bone marrow of the large lytic metastasis is seen, and\n has eroded the cortex of the neck and proximal diaphysis of the right femur,\n although incompletely assessed. The sclerotic lesion in right ischium is\n stable compared to the prior study.\n\n IMPRESSION:\n 1. Interval mild increase in size of enhancing mediastinal masses and\n lymphatic nodes.\n\n 2. Interval increase in size of right renal hypoenhancing mass, which however\n was present in and decreased in size in the interval between \n and .\n\n 3. Stable appearance of multiple small sub-4 mm lung nodules.\n\n 4. Interval development of peripheral discoid densities, that likely\n represent atelectasis, however, cannot completely dependent. No new osseous\n metastasis.\n\n 5. Interval expansion of the soft tissue, replacing marrow in the ovoid lytic\n lesion in the right proximal femur, eroding the cortex of the proximal femoral\n diaphysis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-20 00:00:00.000", "description": "Report", "row_id": 1372173, "text": "NPN 1900-0700:\nEvents: Hct dropped from 27.4 to 25.4, received 1 unit PRBCs.\n\nROS:\nNeuro: alert, oriented to name and place (knows he's in hospital, but said ), disoriented to time and date, confused, follows commands.\n\nResp: On NC 2 LPM SPO2 99-100%, LS CTA to diminished at bases.\n\nCV: HR 69-83, BP 110-134/55-62, with RIJ, dopplerable pulses, on IV antibiotics.\n\nGI/GU: abdomen obese, BS present, tolerated soup and ensure well, with Foley adequate U/o.\n\nInteg: T max 97.1, turned frequently, kept in reverse TB position.\n\nSocial: daughter visited and updated on .\n\nPlan: monitor Hct, transfuse as needed, monitor FS, RISS as needed, transfer when a bed is available.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1372169, "text": "NPN M/SICU ICU day 1 (1900 -0700)\n\nBriefly this is a 70 y/o M w/ PMH significant for Asthma/Htn/Renal Cell CA(RCC). Pt underwent hemiarthroplasty of R hip/R proximal femur replacement for RCC mets. Pt lost approx 3.5 L of blood during procedure requiring 11 U PRBC/5 U FFP/ 5 L LR. Transferred from PACU to M/SICU for monitoring r/t high volume of fluids recieved during procedure.\n\nEvents: Recieved 2 L LR for CVP <10, Bair Hugger initiated for oral temp of 94.4, then D/C @ 0400 as pt was normo-thermic. Mult vent chngs made during shift, curently tolerating CPAP 5/5.\n\nReview of Systems:\n\nNeuro: Pt remains lightly sedated on fent/midaz, arouse to voice, responds appropriately to simple questions. PEARL (sluggish) Lower extremities immobilized to prevent abduction of R hip. Able to wiggle toes/fingers. No c/o pain.\n\nCV: NSR w/ no appreicable ventricular ectopy, ABP 120's-180 systolic, + distal pulses (doppler used for dorsal pedal/post tib), 100cc drained throughout shift from JP drain. Please refer to flowsheet for objective data.\n\nResp: Mult vent chngs made during shift most recent ABG 7.42/30/120 while on AC 40% 500 x 18 PEEP 5, currently tolerating CPAP 40% RR 26 PS5 PeeP 5, RSBI 69. LS clear throughout. Pox 100%\n\nGU/GI: Difficult to ascultate Hypoactive BS, - BM, abd obese/NT/ND, NPO, Patent foley draining >50cc clear yellow. Fluid Status 11 L pos for LOS.\n\nAccess: R IJ TLCL, R a line, all flush and draw appropriately.\n\nPlan: Wean off sedation early this am, extubate, probable c/o to floor. Cont to monitor/maintain heme/resp status. Monitor CVP, replete lytes as necessary. Update pt/fam on POC as it develops.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1372170, "text": "Respiratory Care:\nPatient transitioned from A/C to CPAP/PSV ventilatory support mode. Latest abg results determined a compensated respiratory alkalemia with excellent oxygenation (on A/C).\n\nRSBI = 69.2 on 0-PEEP and 5 cm PSV.\n\nPlan is to place on SBT at this time and extubate this am.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1372171, "text": " 4 ICU nursing progress note:\n Respiratory: Pt weaned and extubated this am. Initially wearing 40% cool neb..sats 100%. Changed to 2l and sats 100%. Encouraging cough and deep breathing. Lung sounds clear. rr 16-20.\n Cardiac: hr 70's sr. bp 100-120's.\n GI: Abdomen obese, hypoactive bs. Small amt brown loose stool. Per family..pt has not been eating past few weeks. Has agreed to have some soup and ensure.\n Pain control: When not moving pt states he has no pain. Given dilauded 1mgm x2 this shift. Pt has most pain when turning.\n s/p Hip repair: JP drain intact..output 100cc/12shift. Sanquinous drainage.\n GU: u/o 20-30cc hr..pt now taking po liqs and slight increase in u/o. Also maybe mobilizing fluid. CVP 3-6.\n Neuro: Initially confused, not knowing where is was. By late afternoon..pt aware of surroundings. Per family pt has been more confused at home.\n Social: Wife and daughter in to visit. Updated on pt condition.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1372172, "text": "RESPIRATORY CARE: PT EXTUBATED TODAY AFTER A SUCCESSFUL SBT\nAND AN RSBI OF 80. CURRENTLY ON O2 AT 2 LPM W/ AN SPO2 OF\n100 % AND DOING WELL. WILL MONITOR RESPIRATORY STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-18 00:00:00.000", "description": "Report", "row_id": 1372168, "text": "RESPIRATORY CARE: PT IS FROM THE OR S/P\nREPLACEMENT OF RIGHT FEMORAL HEAD. PT\nON THE AC MODE AS PER CV. WILL REMAIN\nINTUBATED AND VENTILATED OVER NIGHT AND\nWILL REEVALUATE IN AM.\n" } ]

[ { "category": "Radiology", "chartdate": "2152-09-14 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1029021, "text": " 12:44 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: aneurysm?\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with severe sudden onset headache, neg noncon head CT but pos\n LP.\n REASON FOR THIS EXAMINATION:\n aneurysm?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:10 AM\n No acute SAH and no aneurysm identified.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the head with and without contrast and multiplanar\n reconstructions.\n\n CLINICAL INDICATION: 22-year-old woman with severe sudden onset of headache,\n negative non-contrast head CT, positive lumbar puncture, rule out intracranial\n aneurysm.\n\n COMPARISON: No prior examinations are available at the time of this\n interpretation.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial imaging was performed through\n the brain during the infusion of nonionic intravenous contrast material. The\n images were processed on a separate workstation, multiple rotational and\n maximum intensity projections were submitted for interpretation.\n\n FINDINGS: HEAD CT: There is no evidence of hemorrhage, edema, mass, mass\n effect, or infarction. The ventricles and sulci are normal in caliber and\n configuration for the patient's age. The soft tissues and bony structures\n appear unremarkable. The orbits, the paranasal sinuses, and the mastoid air\n cells are grossly normal.\n\n IMPRESSION: There is no evidence of subarachnoid hemorrhage.\n\n HEAD CTA: On the axial reconstructions, there is prominence of the internal\n carotid bifurcation, likely consistent with volume averaging, there is no\n evidence of stenosis. The right vertebral artery is dominant and the left\n vertebral artery ends in PICA. The basilar artery and the posterior cerebral\n arteries appear within normal limits.\n\n IMPRESSION: Prominent appearance of the internal carotid bifurcation on the\n left as described above, likely consistent with volume averaging, there is no\n evidence of stenosis or aneurysmatic formation. Diminutive left vertebral\n artery which ends in PICA, dominance of the right vertebral artery.\n (Over)\n\n 12:44 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: aneurysm?\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2152-09-15 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1029421, "text": " 11:03 AM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: R/O vertebral dissection\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with 10/10 headaches, Xanthrochromia\n REASON FOR THIS EXAMINATION:\n R/O vertebral dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg FRI 9:14 PM\n Normal CTA of the neck.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old female with 10/10 headaches, xanthochromia.\n Rule out vertebral dissection.\n\n COMPARISON: .\n\n TECHNIQUE: Rapid axial imaging was performed from the aortic arch to the\n skull base during infusion of 80 cc of Optiray intravenous contrast material.\n Images were processed on a separate workstation with display of curved\n reformats, volume-rendered images, and maximum intensity projection images.\n\n NECK CTA: Carotid and vertebral arteries and their major branches are patent\n with no evidence of stenosis, occlusion, or aneurysm formation. The distal\n cervical internal carotid arteries measure 4.3 mm in diameter on the left and\n 4.5 mm in diameter on the right. Note is made of diminutive left vertebral\n artery, which terminates as the PICA. The transverse foramina that the left\n vertebral artery courses through are small, suggeesting that the diminutive\n nature of the artery is most certainly congenital.\n\n IMPRESSION: Normal CTA of the neck.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-15 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1029422, "text": ", J. NSURG SICU-A 11:03 AM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: R/O vertebral dissection\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with 10/10 headaches, Xanthrochromia\n REASON FOR THIS EXAMINATION:\n R/O vertebral dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Normal CTA of the neck.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-15 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 1029434, "text": " 11:32 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: R/O spinal AVM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with aneurysm w/o.\n REASON FOR THIS EXAMINATION:\n R/O spinal AVM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 1:11 PM\n No evidence of arteriovenous malformation. No abnormal enhancement.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the cervical, thoracic, and lumbar spine.\n\n CLINICAL INFORMATION: Patient with aneurysms. Rule out spinal arteriovenous\n malformation.\n\n CERVICAL SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images were\n obtained before gadolinium. T1 sagittal and axial images were obtained\n following gadolinium.\n\n FINDINGS: There is minimal disc bulging identified at C5-6. Otherwise, the\n cervical spine is unremarkable without evidence of stenosis or occlusion or\n foraminal narrowing. There is no evidence of abnormal vascular structures or\n enhancement to indicate arteriovenous malformation.\n\n IMPRESSION: Minimal disc bulging at C5-6.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images were\n obtained before gadolinium. T1 sagittal and axial images were obtained\n following gadolinium.\n\n FINDINGS: There is no evidence of abnormal flow voids or enhancement seen to\n indicate arteriovenous malformation. There is no evidence of disc bulge,\n herniation, or spinal stenosis.\n\n IMPRESSION: No significant abnormalities on MRI of the thoracic spine.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T1 and T2 axial images\n were obtained before gadolinium. T1 sagittal and axial images were obtained\n following the administration of gadolinium.\n\n (Over)\n\n 11:32 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: R/O spinal AVM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS: At L4-5, there is disc bulging identified. There is no abnormal\n vascular structure seen in the lumbar region to indicate arteriovenous\n malformation. No abnormal enhancement is seen. There is a transitional\n vertebra with a rudimentary disc between L5 and S1.\n\n IMPRESSION: No evidence of abnormal flow voids or enhancement to indicate\n intraspinal arteriovenous malformation. Mild disc bulging and early disc\n degenerative change at L4-5 level.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-15 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 1029435, "text": ", J. NSURG SICU-A 11:32 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: R/O spinal AVM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with aneurysm w/o.\n REASON FOR THIS EXAMINATION:\n R/O spinal AVM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of arteriovenous malformation. No abnormal enhancement.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-14 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 1029241, "text": " 3:52 PM\n CAROT/CEREB Clip # \n Reason: 22 year old woman with sudden onset headache one week ago an\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\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 * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CERVICAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with sudden onset headache one week ago and xanthrochromia on\n LP, r/o vessel abnormality\n REASON FOR THIS EXAMINATION:\n 22 year old woman with sudden onset headache one week ago and xanthrochromia on\n LP, r/o vessel abnormality\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n INDICATION: The patient is a 22-year-old female with sudden onset headache\n one week ago. We had initially seen her and had a negative angiogram, but\n subsequently she had an LP which demonstrated xanthochromia and therefore she\n was sent back to and a formal angiogram was performed.\n\n PROCEDURE PERFORMED: Right vertebral artery arteriogram, right common carotid\n artery arteriogram, right internal carotid artery arteriogram, right external\n carotid artery arteriogram, left internal carotid artery arteriogram, left\n external carotid artery arteriogram, and left vertebral artery arteriogram.\n\n ATTENDING:\n PROCEDURE: The patient was brought to the angiography suite. IV sedation was\n given. Following this, both groins were prepped and draped in a sterile\n fashion. Access was gained to the right common femoral artery using a\n Seldinger technique and a 5 French vascular sheath was placed in the right\n common femoral artery. This was connected to a continuous saline infusion. We\n now were able to guide a 5 French 2 catheter coaxially over an 038\n Glidewire into the right vertebral artery and AP, lateral filming done.\n Subsequently, the right common carotid artery, right internal carotid artery,\n the right external carotid artery, the left internal carotid artery, the left\n external carotid artery and the left vertebral artery was catheterized and AP,\n lateral filming done with three-dimensional imaging where appropriate. This\n failed to reveal any source of hemorrhage and therefore the catheter was taken\n out. The vascular sheath was removed and manual compression applied for\n closure of the right femoral artery puncture site.\n\n (Over)\n\n 3:52 PM\n CAROT/CEREB Clip # \n Reason: 22 year old woman with sudden onset headache one week ago an\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS: Right vertebral artery arteriogram demonstrates normal filling of\n the right vertebral artery and the basilar artery along with its branches. A\n small PICA is seen with a large AICA-PICA configuration on the right side.\n Both superior cerebellar arteries and posterior cerebellar arteries are seen\n normally. There is no reflux into the left vertebral artery.\n\n Right common carotid artery arteriogram shows no obvious anomalies. The right\n external carotid artery and its branches are seen normally and the right\n internal carotid artery and its branches are seen normally. The venous phase\n does not reveal any anomalies. There is predominant drainage into the right\n transverse sinus. The anterior communicating segment is well visualized.\n Right internal carotid artery arteriogram with three-dimensional imaging\n demonstrates normal filling of the right internal carotid artery. Both A2s\n fill on this injection. The middle cerebral artery and its branches are seen\n normally. There is no evidence of aneurysms, AV malformation or vasculitis on\n these views.\n\n The right external carotid artery arteriogram shows normal filling of the\n right external carotid artery and its branches. There is no evidence of AV\n fistula.\n\n Left internal carotid artery arteriogram shows the internal carotid artery\n fills well along its cervical, petrous, cavernous and supraclinoid portion.\n The middle cerebral artery and the anterior cerebral artery is seen normally.\n There is a prominent posterior communicating artery, however this is not fetal\n in origin.\n\n Left common carotid artery arteriogram shows normal common carotid artery\n bifurcation with no evidence of stenosis.\n\n Left external carotid artery arteriogram shows normal filling of the left\n external carotid artery and its branches. There is no evidence of AV fistula.\n Left vertebral artery arteriogram essentially shows a diminutive left\n vertebral artery which predominantly ends in the left PICA.\n\n MODERATE SEDATION was provided by administering 50 mcg of Fentanyl and 1 mg of\n Versed in divided doses throughout the 55 minute intraservice time during\n which the patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: underwent cerebral arteriography for\n xanthochromia and severe headache considered to be aneurysmal. No source of\n hemorrhage was found and there was no evidence of vasculitis or mycotic\n aneurysm.\n\n\n (Over)\n\n 3:52 PM\n CAROT/CEREB Clip # \n Reason: 22 year old woman with sudden onset headache one week ago an\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-09-15 00:00:00.000", "description": "Report", "row_id": 1645590, "text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: ORIENTED X3. MAE, WEAK NORMAL STRENGTH. C/O HEADACHE AND BACKPAIN RATING ON SCALE; TREATING WITH 2MG MORPHINE, GIVEN WITH GOOD EFFECT. PUPILS BRISK AND REACTIVE AT 3MM. FLAT/HOB RESTRICTIONS OFF, PT CAN OOB TO COMMODE W/ASSIST. ? MRI IN AM PRIOR TO IR FOR SPINE.\n\nCV: NSR HR 60-80. NO ECTOPY. SBP 100-120 (GOAL TO MAINTAIN SBP <140). + PP. + FEM PULSE. EXTREMITIES WARM, NORMAL IN COLOR.\n\nRESP: LUNGS CLEAR. NO C/O SOB. SAT'S 97-99% RA.\n\nGI/GU: ABD SOFT. NT. ND. NO BM. NO C/O NAUSEA. ADVANCING DIET AS TOLERATES. MAINTAINENCE FLUIDS 80CC NS CONT OVERNIGHT, TO KVO AS PO'S. FOLEY REMOVED AT 2330, DTV BETWEEN 0600-0800. COMMODE AT BS.\n\nSOCIAL: PARENTS AND BOYFRIEND AT BEDSIDE DURING EVENING, WILL BE BACK IN AM.\n\nPOC: NEURO CHECKS EVERY 2 HRS. ? MRI. IR FOR SPINE. MONITOR PAIN/COMFORT, PRN MORPHINE. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-14 00:00:00.000", "description": "Report", "row_id": 1645589, "text": "Pt is s/p headache ? aneurism.\n\nN - Patient has been awake and oriented this shift. She has had a headache with aching description that radiates down her spine. Treated with PRN morphine with good effect. PERRL at 3mm bilaterally, MAE with equal strength, no droop. Angio done this shift with negative results, no aneurism noted IR MD.\n\nCV - HR NSR without ectopy. BP stable, goal SBP to be less than 140mmHg. Pulses are palpable in radial and pedal locations. Right femoral accessed for IR, site intact, dressing CDI and pulses palpable in distal right lower extremity. Pt has remained afebrile.\n\nR - Patient is on RA with clear lung sounds and sats 98% to 100%, no cough and no SOB.\n\nGU - patient has been using commode prior to IR, now to be flat until 1130pm, patient has history of UTI and difficulty urinating. Post IR patient unable to void, planned for foley insertion.\n\nGI - Abdomen soft, nontender without nausea/vomiting. She has been ordered a regular diet, continue to monitor.\n\nIV - Left wrist PIV intact, flushes well. IVF had been infusing at 80mL/hr of NS, continue to monitor, ? d/c IVF once PO fluids initiated.\n\nSKIN - intact besides ANGIO site, continue to monitor.\n\nP/S - Family at bedside, updated on plan of care, supportive to patient. Plan to keep them up to date on plan of care.\n\nPLAN - monitor neuro status, monitor angio site per protocol, plan for ? MRI when ordered for further diagnosis, pain control,\n" } ]

[ { "category": "Radiology", "chartdate": "2104-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832648, "text": " 2:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line change\n Admitting Diagnosis: LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man, to be recipient of liver transplant. Preop evaluation.\n\n REASON FOR THIS EXAMINATION:\n line change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation for liver transplant candidate; status\n post central line exahange.\n\n COMPARISON: , at 00:56.\n\n CHEST, AP PORTABLE RADIOGRAPH: The cardiac, mediastinal and hilar contours\n are stable in appearance. The endotracheal tube tip is approximately 4 cm\n above the carina. The right internal jugular pulmonary arterial catheter has\n been exchanged for a central line, with the tip terminating at the cavoatrial\n junction. Allowing for supine technique, the lungs are grossly clear. A\n nasogastric tube tip overlies the stomach, which appears gaseously distended.\n Osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Satisfactory placement of right IJ central venous line without evidence of\n pneumothorax.\n\n 2. Gaseous distension of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2104-07-22 00:00:00.000", "description": "CHEST (PRE-OP AP ONLY)", "row_id": 832548, "text": " 4:03 PM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: Preop for liver transplant.\n Admitting Diagnosis: LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man, to be recipient of liver transplant. Preop evaluation.\n REASON FOR THIS EXAMINATION:\n Preop for liver transplant.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop evaluation for liver transplant.\n\n CHEST, AP PORTABLE RADIOGRAPH: The cardiac, mediastinal and hilar contours\n are unremarkable with a minimally unfolded and tortuous aorta. The lungs are\n clear. The soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.\n\n" }, { "category": "Radiology", "chartdate": "2104-07-25 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 832869, "text": " 2:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: Please assess hepatic vein and artery, portal vein and bile\n Admitting Diagnosis: LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with elevation in Alk Phos, POD 3 OLT.\n\n REASON FOR THIS EXAMINATION:\n Please assess hepatic vein and artery, portal vein and bile ducts.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevation of alkaline phosphatase, post op day #3 for liver\n transplant.\n\n FINDINGS: Comparison is made to Doppler study dated .\n\n The liver appears homogeneous. Doppler evaluation of the portal vein and\n hepatic veins is normal. On today's examination, the peak systolic velocity\n in the main hepatic artery is 83.1 cm/second. This is reduced from previous.\n The waveform is normal. The right and left hepatic arteries are visualized\n and appear normal. The RI in the RHA is 0.72 as compared with 0.6 on the prior\n study. The RI in the LHA is 0.79 as compared with 0.65 previously. There is\n no ascites.\n\n IMPRESSION: Normal liver Doppler.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832576, "text": " 12:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man, to be recipient of liver transplant. Preop evaluation.\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 59 y/o male with hepatocellular carcinoma requiring liver\n transplant.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from .\n\n FINDINGS: Heart size is normal. Mediastinal and hilar contours are\n unremarkable. The lungs are clear. No pleural effusions. ET tube is\n appropriately positioned at the thoracic inlet. The NG tube tip is in the\n stomach. Right IJ introducer sheath tip is at the right brachiocephalic/upper\n SVC. The Swan-Ganz catheter tip is at the right pulmonary artery. -\n drain is observed in the right upper quadrant. Osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: Appropriate positioning of ET, NG, right IJ introducer sheath and\n Swan-Ganz catheter. No acute cardiopulmonary process on chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2104-07-23 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 832608, "text": " 9:44 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: s/p liver transplant, please eval for hepatic vasculature an\n Admitting Diagnosis: LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with\n REASON FOR THIS EXAMINATION:\n s/p liver transplant, please eval for hepatic vasculature and portal vein flow.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P liver transplant.\n\n FINDINGS:\n\n No priors for comparison. The patient is 1 day post transplant.\n\n The liver is homogeneous without focal abnormality. The visualized vessels\n including the portal and hepatic veins demonstrate patency and normal wave\n forms. For technical reasons, the left hepatic vein could not be well\n visualized. The peak systolic velocity in the main hepatic artery is slightly\n elevated at 210 cm/s. RI is normal and the wave forms have a normal\n configuration.\n\n There is no ascites. The anastamosis is visualized and appears within normal\n limits.\n\n IMPRESSION:\n\n Examination is essentially within normal limits with the exception of elevated\n peak systolic velocity in the main hepatic artery. The significance of this is\n uncertain, however, may simply be within normal limits. Repeat examination in\n 24 hours is suggested. This case has been discussed with the transplant\n resident.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2104-07-22 00:00:00.000", "description": "Report", "row_id": 181092, "text": "Baseline artifact\nSinus rhythm\nConsider left atrial abnormality but may be within normal limits\nSince previous tracing of , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2104-07-23 00:00:00.000", "description": "Report", "row_id": 1484785, "text": "RESP CARE: Pt recieved from OR intubated with ETT 7.5/ 23 lip. Pt placed on SIMV 650/14/1.0/5/5 per Dr. . FI02 weaned to .40 with acceptable 02 sats/ ABGs. RSBI-84. PLAN: Wean to extubate this am\n" }, { "category": "Nursing/other", "chartdate": "2104-07-23 00:00:00.000", "description": "Report", "row_id": 1484786, "text": "data/action: adm. from or @ 2345 intub. initially sb/p 88/-> 500cc n/s fliud bolus w/ good response sb/p>110. pt not reversed but awake and mae w/in 15min. nods yes to pain in abd.-med. w/ morphine 2mg w/ good relief. sedated on ppf 30-40mcg/kg/min for vent control/comfort->to wean and extub this am-per orders.\nabd. dsg d&i. jp's drge small amt sero-sang. hct stable.\nbs-170-250 covered by sliding scale insulin.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-23 00:00:00.000", "description": "Report", "row_id": 1484787, "text": "Resp Care\nPt received on SIMV and weaned to CPAP-parameters noted-in a.m. Pt extubated at 1600 to a 50% aerosol mask. Doing well. Breath sounds are essentially clear bilat.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-23 00:00:00.000", "description": "Report", "row_id": 1484788, "text": "Condition Update A:\nPlease refer to careview and remarks for data.\nNEURO: Pleasant A&Ox3, MAE, follows commands. Speach soft and clear. Medicated with MSO4 1-2mg q1-3h IVP with good effect on pain. Describes pain as \"feeling bloated.\"\n\nCV: Afeb. HR NSR 60-70, no ectopy. SBP 150-180. Discussed with SICU team (Dr. ) and Transplant team ( Drs' , , and ). Goal SBP 100-190 and mean <110. CVP 4-7. BLE scant nonpit edema. RIC, trauma, and CCO lines d/c. CCO changed over wire to 3L-CVL.\n\nRESP: Tol extubation on open face tent 12L 50%. LS CTA with clear/dim BLL.\n\nGI/GU: NGT d/c. Abd soft distended/ feels bloated/ appropriately tender. BS absent. Medicated with Zofran x1 at 1800 for c/o nausea with effect. Foley draining adequate ampounts of concentrated urine.\n\nENDO: Glucose checked q6h and treated per RISS.\n\nSKIN: Original surgical dressing intact with small amount of serosang drainage. JP's with minimal output this shift.\n\nSOCIAL: Mrs. and children in to visit this afternoon. Support and plan of care given to pt and family.\n\nPLAN:\n Monitor hemodynamics, goal SBP 100-190 with mean <110.\n Monitor resp status, decrease O2 delivery as pt tolerates.\n Monitor comfort level, admin pain med PRN.\n Minitor i/o (urine and JP'S).\n Cont with ICU care and monitoring, call H.O. with changes.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-24 00:00:00.000", "description": "Report", "row_id": 1484789, "text": "data/action: vss. major complaint- full, bloated feeling from stomach.\nvery uncomfortable w/ nausea- zofran x2 w/ slight relief. belching x1\nmaalox given for acid digestion. abd. soft distended no bowel sounds\nheard. pt npo except for meds. jp's min. drge serous.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-24 00:00:00.000", "description": "Report", "row_id": 1484790, "text": "7p-9:30 pm\n\nPt transfer to 10. No change. A+OX3. VSS, afebrile. warm, dry, no edema. Clear in upper lobes, dimish at bases. 3L NC. abd - +bs except LLQ. JP 1,2 - d/c/i - ss drainage. abd dressing site d/c/i. pain per pt in abd - relief with morphine push. Nausea treated zofran ivp - good effect. Transfer note written by . No questions per pt. No personal belonging.\n" } ]

[ { "category": "Radiology", "chartdate": "2177-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977418, "text": " 12:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and variceal bleed tranferred to MICU for AMS.\n Now with hypoxia after intubation.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Patient with cirrhosis and variceal bleed with hypoxia.\n\n Comparison is made with prior study performed two hours earlier.\n\n ET tube is in standard position. Left lower retrocardiac opacity is new.\n Right lower perihilar opacity is unchanged. These are concerning for\n atelectasis and/or aspiration. There is no pneumothorax. Note is made that\n the left CP angle was excluded on the film.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2177-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977621, "text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening lung fields seen on previous film, please eval for\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and variceal bleed tranferred to MICU for\n AMS.\n REASON FOR THIS EXAMINATION:\n worsening lung fields seen on previous film, please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Variceal bleeding.\n\n Feeding tube has been removed. Cardiac silhouette remains enlarged with\n associated vascular engorgement and perihilar haziness accompanied by an\n asymmetrical perihilar alveolar process, worse on the right than the left. As\n compared to the recent study, this has minimally worsened in the interval and\n likely represents asymmetric pulmonary edema from either fluid overload or\n CHF. Layering right pleural effusion is also slightly increased.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977404, "text": " 11:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and variceal bleed tranferred to MICU for AMS.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, with acute variceal bleeding.\n\n COMPARISON: .\n\n PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST AT 11:40 A.M: The endotracheal tube\n terminates approximately 4 cm above the carina. This exam is technically\n limited by patient rotation, low lung volumes, and exclusion of the extreme\n left costophrenic angle from the radiograph. However, a region of increased\n opacity in the medial right lower lung may represent a developing focal\n consolidation, particularly aspiration is a consideration. Followup is\n recommended. The heart size is at the upper limit of normal. The pulmonary\n vasculature is normal and there is no pulmonary edema. There are no obvious\n pleural effusions.\n\n IMPRESSION: Right lower lung perihilar opacity may represent aspiration or\n acute infection. Follow up with repeat radiograph is recommended. No heart\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2177-08-01 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 977433, "text": " 2:19 PM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: Please evaluate for TIPS patency and mark for paracentesis i\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 yo M with NASH cirrhosis s/p TIPS revision with balloon dilatation on .\n Please doppler for TIPS and mark for paracentesis if ascites present.\n REASON FOR THIS EXAMINATION:\n Please evaluate for TIPS patency and mark for paracentesis if ascites present.\n ______________________________________________________________________________\n FINAL REPORT\n LIVER ULTRASOUND WITH DOPPLER EVALUATION:\n\n CLINICAL HISTORY: 52-year-old male with NASH-cirrhosis status post TIPS\n revision with balloon dilatation on . Please evaluate TIPS and mark for\n paracentesis if ascites present.\n\n Comparison is made to the prior study dated .\n\n The liver is unchanged in appearance. There is a right pleural effusion and a\n small-to-moderate amount of ascites present. A spot for paracentesis was not\n marked at this time.\n\n Evaluation of the TIPS demonstrates maximum velocities in the proximal, mid\n and distal portion of the TIPS to be approximately 100, 155, and 209 cm/sec\n (previously 117, 123, and 196). Though the average velocities throughout the\n TIPS are overall unchanged when compared with the prior study, the average\n maximum velocity measures in the distal portion of the TIPS catheter and\n measures slightly higher on the current examination.\n\n Evaluation of the distal right and left portal veins is limited on this\n examination. The main portal vein is patent and demonstrates hepatopetal flow\n with a velocity of 60 cm/sec (previously 38 cm/sec).\n\n IMPRESSION:\n\n Patent TIPS catheter with wall-to-wall flow. Maximum peak velocities in the\n proximal, mid and distal portion of the TIPS catheter are overall unchanged\n since the prior study. However, the average velocity in the distal portion of\n the TIPS appears to be slightly higher on the current examination, not\n a significant difference, however.\n\n These findings were discussed with Dr. at approximately 5:30 p.m. on\n .\n\n\n\n (Over)\n\n 2:19 PM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: Please evaluate for TIPS patency and mark for paracentesis i\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2177-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977605, "text": " 10:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for placement of NJ tube\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and variceal bleed tranferred to MICU for AMS.\n\n REASON FOR THIS EXAMINATION:\n Please evaluate for placement of NJ tube\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 22:29\n\n COMPARISON: .\n\n INDICATION: Feeding tube placement.\n\n Feeding tube initially coils within the proximal esophagus, before eventually\n coursing to the proximal stomach although the majority of the radiodense tip\n of the tube is proximal to the GE junction. This finding was communicated to\n Dr. by Dr. on . Since the prior radiograph,\n cardiac silhouette has increased in size accompanied by vascular engorgement,\n bilateral asymmetrical airspace opacities, right greater than left, and a\n layering right pleural effusion. Findings may be due to asymmetric edema from\n fluid overload or CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977643, "text": " 9:22 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: suboptimal xray this morning, please re-film, eval for CHF v\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with variceal bleed, altered MS, worsening chest xray\n REASON FOR THIS EXAMINATION:\n suboptimal xray this morning, please re-film, eval for CHF v. pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: Prior study of earlier the same date.\n\n INDICATION: CHF. Altered mental status.\n\n Congestive heart failure has improved with decreasing asymmetrical pulmonary\n edema, particularly in the right lung. Bilateral small pleural effusions are\n present, difficult to compare due to positional differences, but probably\n improved on the right side. Bibasilar atelectasis is noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-07-17 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 975204, "text": " 8:33 AM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Pt with cirrhosis and TIPS. Please assess patency\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 yo M with cirrhosis s/p TIPS and revison of TIPS. Short interval f/u\n based on last duplex.\n REASON FOR THIS EXAMINATION:\n Pt with cirrhosis and TIPS. Please assess patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with cirrhosis and TIPS, assess patency of TIPS.\n\n COMPARISON: Liver Doppler ultrasound .\n\n FINDINGS: The liver is shrunken and echogenic but no focal lesions are\n identified. Again seen is a large right pleural effusion and a small amount\n of ascites. There is no biliary dilatation. Gallbladder polyps are again\n noted.\n\n Color flow and Doppler images of the TIPS were performed. Wall-to-wall flow\n was demonstrated throughout the TIPS and the velocity of flow within the TIPS\n ranges from 85 to 125 cm/sec which is essentially unchanged from the prior\n exam. Hepatopetal flow is documented in the main portal vein and the velocity\n was 48 cm/sec. Flow in the left portal vein and the right portal vein is not\n identified which is also unchanged from the prior exam.\n\n IMPRESSION: Patent TIPS with wall-to-wall flow and velocities ranging from 85\n to 112 cm/sec. Unchanged right pleural effusion and a small amount of\n ascites.\n\n" }, { "category": "Radiology", "chartdate": "2177-07-18 00:00:00.000", "description": "REVISN HEPATIC SHUNT TIPS", "row_id": 975343, "text": " 7:46 AM\n REDO TIPS Clip # \n Reason: TIPS venogram and coronary vein embolization\n Contrast: VISAPAQUE Amt: 175\n ********************************* CPT Codes ********************************\n * REVISN HEPATIC SHUNT TIPS MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with NASH cirrhosis, prev TIPS and embolization, now recurrent\n variceal bleeding. Will be admitted \n REASON FOR THIS EXAMINATION:\n TIPS venogram and coronary vein embolization\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a 53-year-old man with mask cirrhosis status post TIPS\n recurrent bleeding.\n\n RADIOLOGISTS: The procedure was performed with Drs. and , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on angiographic table and the right neck was prepped and draped in\n standard sterile fashion. After injection of 5 cc of 1% lidocaine in the\n neck, access was gained to the right internal jugular vein under\n ultrasonographic guidance and a 4.5 French micropuncture sheath was placed. A\n 0.035 wire was placed through the micropuncture sheath up to the level\n of the inferior vena cava under fluoroscopic guidance. Then, the\n micropuncture sheath was then exchanged for 7-French bright tip sheath. The\n inner dilator was removed and a 5-French Cobra catheter was placed over the\n wire up to the level of the IVC and access was gained into the hepatic vein,\n hepatic vein and then further into the TIPS under fluoroscopic guidance. The\n Cobra catheter was exchanged for a 5-French straight Omni Flush catheter and\n the wire was then removed. Pressure measurements were obtained at the level\n of the portal vein, TIPS, hepatic vein and IVC with a pressure gradient of 20\n mm Hg. Subsequently, a venogram was performed demonstrating an area of\n narrowing at the distal TIPS, and no areas of vessel dilation or varices. The\n splenic venogram demonstrates no varices detected. Based on these diagnostic\n findings, it was decided to perform balloon dilation of the stenotic area at\n the TIPS with a high-pressure balloon. An Amplatz wire was then advanced\n through the catheter and the catheter was removed. A balloon was advanced up\n to the level of the TIPS and multiple balloon dilations were performed up to\n 20 atm pressure. The balloon was removed and a followup venogram demonstrates\n good angiographic results. Pressure measurements were obtained after the\n balloon dilation of the stenotic area in the portal vein, TIPS, hepatic vein\n and the IVC with a gradient of 7 mm Hg. The patient tolerated the procedure\n well. Moderate sedation was provided by administering divided dose of 50 mcg\n of fentanyl and 0.5 mg of Versed throughout the total intra service time of 20\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n (Over)\n\n 7:46 AM\n REDO TIPS Clip # \n Reason: TIPS venogram and coronary vein embolization\n Contrast: VISAPAQUE Amt: 175\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. TIPS venogram demonstrates no open large varices, and a tight stenosis on\n the hepatic venous side of the TIPS stent.\n 2. Successful dilation of that stenosis with a 10-mm balloon and with good\n angiographic results.\n 3. Initial gradient of 20 mm Hg between the portal vein and the right atrium\n that was decreased to 7 mm Hg after balloon angioplasty of the TIPS narrowing.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2177-07-19 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 975503, "text": " 12:02 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOP ABD/PEL LIMITEDClip # \n Reason: please perform dopplers to assess TIPS flow/velocities and r\n Admitting Diagnosis: CLOTTED TIPS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 yo M with NASH cirrhosis s/p TIPS revision with balloon dilatation on \n REASON FOR THIS EXAMINATION:\n please perform dopplers to assess TIPS flow/velocities and r/o focal lesions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with TIPS revision on .\n\n COMPARISON: .\n\n FINDINGS: The liver is shrunken and echogenic consistent with cirrhosis.\n There is a large right pleural effusion and small amount of ascites.\n Gallbladder polyps are again seen.\n\n The TIPS stent is seen within the right lobe of the liver. Wall-to-wall flow\n is demonstrated with TIPS velocities ranging from 116 cm/sec prox, 124 mid,\n 137-157 distal, which are increased compared to the prior examination.\n Hepatopetal flow is demonstrated in the portal vein, with velocities ~38\n cm/sec. Flow in the left and right portal veins is again not identified.\n\n IMPRESSION:\n 1. Patent TIPS with wall-to-wall flow and velocities increased now ranging\n from 116 to 157 cm/sec.\n 2. Small amount of ascites and large right-sided pleural effusion.\n\n" }, { "category": "Echo", "chartdate": "2177-07-17 00:00:00.000", "description": "Report", "row_id": 75048, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic regurgitatation.\nHeight: (in) 71\nWeight (lb): 180\nBSA (m2): 2.02 m2\nBP (mm Hg): 110/70\nHR (bpm): 82\nStatus: Outpatient\nDate/Time: at 13:00\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: Normal RA size.\n\nLEFT VENTRICLE: Moderately dilated LV cavity. Overall normal LVEF (>55%).\nTransmitral Doppler and TVI c/w normal LV diastolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Small vegetation on\naortic valve. No AS. Increased transaortic velocity related to increased\nstroke volume due to AR. Moderate to severe (3+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The left ventricular cavity is\nmoderately dilated. Overall left ventricular systolic function is normal\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith normal LV diastolic function. Right ventricular chamber size and free\nwall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are moderately thickened. There is a small vegetation on the\naortic valve. There is no valvular aortic stenosis. The increased transaortic\nvelocity is likely related to increased stroke volume due to aortic\nregurgitation. Moderate to severe (3+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the aortic valve\nvegetation appears smaller. Left ventricular size and aortic regurgitation\nseverity is similar.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-08-01 00:00:00.000", "description": "Report", "row_id": 1352676, "text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS.\n\n53 Y/O MALE WITH PMH NASH-CIRRHOSIS S/P MULTIPLE UPPER GI BLEEDS (LAST BLEED ), TYPE II DM, GASTRITIS, INTERNAL HEMORRHOIDS, HX THROMBOCYTOPENIA AND SPLENOMEGALY, PANCYTOPENIA, ARTHRITIS, DIVERTICULOSIS, AV ENDOCARITIS , LUCUNAR INFARCTS. PT FROM 10 FOR MS CHANGES.\n\nPE:\n\nNEURO: AROUSABLE TO STERNAL RUB. NOT FOLLOWING COMMANDS. PERRL, , SPONTANEOUSLY MOVEMENT OF ALL FOUR EXTREMITIES. AREA TO BE MD AWARE. +GAG/COUGH. NO PAIN NOTED.\n\nCARDIAC: HCT: 27.8.PLATELETS 58. PT: 14.4,INR: 1.3. NSR. HR: 60-80'S. SBP: 92-150/30-40'S. +RADIAL, FEMORAL, POPITEAL,PT AND DP X2. CSL ON.\n\nPULM: INTUBATED. CPAP/405/5 PEEP/5 PS. POX: 98-100. LS: R+LUL CLEAR, DIMINISHED BIBASILAR. SX FOR SM AMTS TO CLEAR-WHITE THICK SECRECTIONS.\n\n\nGI: NPO. DOBHOFF PLACED,PLACEMENT CONFIRMED VIA ENDOSCOPY. ENDOSCOPY TODAY BANDS INTACT AND NO APPARRENT ACTIVE BLEEDING. CONTINUES ON SANDOSTATIN GTT. ABD:D,+HYERACTIVE BS X3,S,NT. LG BROWN GUIAC POS STOOL X1.\n\nGU: FOLEY WITH QS . 40MG IV LASIX GIVEN WITH GOOD EFFECT. LYTES WNL.\n\nENDO: FS QID. COVERAGE PER RISS. QHS LANTUS. FS: 136-152.\n\nIVL: PIV'S X4, SITES WNL AND DRESSINGS CDI.\n\nPSYCH/SOCIAL: WIFE BY MICU MD AND UPDATED OF HUSBAND'S CONDITION/TRANSFER.\n\nPLAN: Q 4 HOUR NEURO CHECKS. CONTINUE LACTOLOSE FOR GOAL BM THREE TIMES PER DAY. AGGRESSIVE PULM HYGIENE. TIRTATE VENT SUPPORT AS TOLERATED. GOAL IS FOR PT TO REMAIN INTUBATED OVERNIGHT WITH POSSIBLE EXTUBATION IN AM DEPENDING ON MS. Q4 HOUR HCT'S. REPOSITION Q 2. READDRESS NUTRITION STATUS IN AM. MONITOR FOR PAIN. PROVIDE SUPPORTIVE CARE TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2177-08-02 00:00:00.000", "description": "Report", "row_id": 1352677, "text": "Resp Care,\nPt. remains intubated overnoc. IPS off due to resp alkolosis. VT remains high. RR continues to drop to 5, pt. placed on MMV, but pt. continues to breathe mosstly on his own. RSBI 17 this am, plan extubation.\n" }, { "category": "Nursing/other", "chartdate": "2177-08-01 00:00:00.000", "description": "Report", "row_id": 1352675, "text": "resp care - Pt was transfered to this unit in order to be intubated for an EGD procedure. Pt remains intubated at this time, and on minimal settings of PSV. ABG showed resp alkalosis with good oxygenation. Plan is to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2177-08-02 00:00:00.000", "description": "Report", "row_id": 1352678, "text": "condition update\nD: pt sedated at start of shift. slightly arousable to sternal rub. pupils equal and reactive to light. withdraws to painful stimuli. more awake during the shift. trying to sit up in bed. continues to not follow commands. eyes open spontaneously and pt very resstless in be. Spoke with Dr. and pt restarted on lowdose propofol. pt apprears more comfortable. propofol currently on 20mcg/kg/min.\ncardiac: pt nsr rate 60-70's. sbp greater than 80 acceptable per Dr. . sbp in the 90's. hct 27-28 pt transfused with 2 units of prbc. platelets down to 40 and transfused with one unit of pooled platelets.\nresp: pt remains on cpap 5 peep and 0 pressure support. pt suctioned for thick tan sputum. pt with good cough. see flowsheet for abg. Dr. aware.\ngu: foley patent and clear yellow urine.\ngi: pt remains npo and feedig tube is patent. abd soft with positive bowel sounds. pt received one lactulose enema with fair response. pt with liquid stool brownz/melanotic. guiac positve.\nskin: duoderm intact on coccyx. left arm abrasion is clean and dry and\nopen to air.\na: ? wean propofol and extube this am. serial hcts and platelets. wife called and will be in today. she would. like to meet with team to discuss plans. .\nr: pt comfortable on cpap with 5 and 5 of pressure support. risbi good this am. pt receiving additional unit of blood.(#2) and platelets infused labs are pending. lactulose effecitve in producing stool. pt more awake this am and wean propofol for possible extubation.\n" }, { "category": "Nursing/other", "chartdate": "2177-08-02 00:00:00.000", "description": "Report", "row_id": 1352679, "text": "Respiratory Care\nPt was extubated today at 0945 per team at rounds. Post extubation vitals were HR 86, BP 108/43, RR 12 and non-labored, SpO2 100% on 3L via NC. Pt had a mile cough effort due to mental status, pt had a gag and a cuff leak. No stridor was noted and lung sounds were clear. Will continue to follow pt for post extubation care.\n" }, { "category": "Nursing/other", "chartdate": "2177-08-02 00:00:00.000", "description": "Report", "row_id": 1352680, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: OFF ALL SEDATION, PT TO NOXIOUS STIMULI THIS AM, DOES NOT FOLLOW COMMANDS, WILL OPEN EYES WHEN WIFE CALLS HIM, MINIMAL VERBAL RESPONSE TO WIFE- NONE TO STAFF, MAE ON BED BUT NOT TO COMMAND, PURPOSEFUL MOVEMENT. PERRL\nCV: T MAX 99.2. HR 80-90'S NSR, SBP 80-105. EXTREMITES WARM, BPPP\nRESP: PT EXTUBATED WITHOUT INCIDENT, CURRENTLY ON NC AT 3 LITERS WITH SATS 98-100%. BS CLEAR BUT DIMINSHED IN BASES\nGI: ABD SOFT, + BS, LACTULOSE INCREASED TO QID, LACTULOSE ENEMA GIVEN X1= 400 CC LIQUID BROWN QUAIAC + STOOL, STARTED ON TF AT 10CC/HR.\nGU: CLEAR YELLOW URINE IN ADEQUATE AMTS\nENDO: BS 140-155 RANGE, SLIDING SCALE INSULIN X1\nA/P; CONT TO MONITIOR HEMODYNAMICS AND NEURO STATUS CLOSELY, PT REMAINS ENCEPHALOPATHIC= CONT LACTULOSE PO WITH GOAL OF 3 BM'S PER DAY, SERIAL HCT Q12HRS. ? TRANSFER TO FLOOR IN AM\n" }, { "category": "Nursing/other", "chartdate": "2177-08-03 00:00:00.000", "description": "Report", "row_id": 1352681, "text": "NPN (NOC):\n\nNEURO: PT AROUSES TO VOICE AND WILL ANSWER QUESTIONS W/ \"YES\" OR \"NO\" ONLY. FOLLOWS COMMANDS INCONSISTENTLY. LIFTS AND HOLD ALL 4 EXTS. HE IS INTERMITTANTLY RESTLESS AND PULLING AT TUBES DESPITE HAND RETRAINTS (PULLED OUT DOBOFF). NO ATTEMPTS MADE TO GET OOB. BED IN LOW, LOCKED POSITION W/ BED ALARM ON.\n\nCV: TACHYCARDIC WHEN RESTLESS, OTHERWISE HR'S IN 80'S TO 90'S. SBP'S STABLE.\n\nRESP: RR TEENS, REG, UNLABORED AT REST. SATS HIGH 90'S ON 4 LITERS NC. BS'S CLEAR, COUGH NONPRODUCTIVE.\n\nGI: NPO NOW THAT DOBOFF OUT. LACTULOSE GIVEN PR AT MN AND HAS HAD 3 LOOSE STOOLS SINCE THEN.\n\nF/E: UO STILL ~ 100/HR AND I&O WAS NEGATIVE 1200 CC'S AT MN. AM K = 3.0, 40 MEQS UP TO RUN OVER 5 HRS AT 6AM.\n" }, { "category": "ECG", "chartdate": "2177-08-01 00:00:00.000", "description": "Report", "row_id": 196754, "text": "Sinus rhythm. The P-R interval is short without evidence of pre-excitation.\nDiffuse non-specific ST-T wave changes. Compared to the prior tracing\nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2177-08-02 00:00:00.000", "description": "Report", "row_id": 196755, "text": "Sinus rhythm. Poor R wave progression. Cannot rule out old anteroseptal\nmyocardial infarction. Lateral ST-T wave changes which are non-specific.\nCompared to tracing of there is no significant diagnostic change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-05-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 761591, "text": " 3:26 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: r/o abscess/leak\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with perf'd diverticulitis s/p sigmoidectomy\n REASON FOR THIS EXAMINATION:\n r/o abscess/leak\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: ? abscess vs leak in patient s/p sigmoidectomy for\n diverticulitis.\n\n TECHNIQUE: Helically aquired contiguous axial images were obtained from the\n lung bases to the pubic symphysis after the administration of 150 cc of\n Optiray. Non-ionic contrast was used, secondary to h/o allergies. Coronal\n reformations were subsequently obtained and reviewed.\n\n Comparison: .\n\n CT ABDOMEN W/CONTRAST: The heart is notable for poly-chamber enlargement.\n There is redemonstration of right lower lobe atelectasis with geograhic\n pattern suggestive of post-radiation change. Again see is right lower lobe\n effusion with split pleural sign, suggesting loculation and possible empyema.\n A small left effusion is also present which is also new since the prior study.\n The liver, spleen, adrenal glands, pancreas, kidneys and ureters are\n unremarkable and unchanged. A left renal exophytic cyst is again noted. The\n gallbladder fluid is noted to have increased attenuation likely due to\n contrast excretion from prior study. A trace amount of fluid is noted in\n pouch and a moderate amount of fluid is noted in the pelvis with no\n evidence of abscess formation or abnormal air pockets. The distal small bowel\n and colon is well opacified to the ostomy. There is no evidence of contrast\n extravasation to suggest leak. A midline incision site with skin clips is\n noted with no abnormal fluid collections in the subcutaneous tissues. There is\n no retroperitoneal, mesenteric, deep pelvic, or inguinal lymphadenopathy.\n There is no free air in the abdomen or pelvis.\n\n CT PELVIS WITH IV CONTRAST: Calcification in uterus consistent with fibroid.\n Urinary bladder unremarkable. No lymphadenopathy.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are seen.\n Degenerative changes are noted in the lumbar spine.\n\n IMPRESSION:\n 1) No evidence of abscess or leak, s/p sigmoid colon resection.\n 2) Moderate amount of free fluid in the pelvis tracking up to \n pouch.\n 3) Stable appearance of right lower lobe atelectasis vs post-radiation change\n and apparently loculated small right pleural effusion. Empyema cannot be\n excluded.\n (Over)\n\n 3:26 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: r/o abscess/leak\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4) Interval formation of small left pleural effusion.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 761033, "text": " 3:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p ex lap, hartmanns, intubated\n REASON FOR THIS EXAMINATION:\n check ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post exploratory laparotomy and Hartmann pouch. Still\n intubated post-op.\n\n COMPARISON: \n\n SUPINE AP CHEST: Patient is status post unchanged median sternotomy.\n Endotracheal tube has tip 4 cm above the carina. NG tube has tip in the\n stomach. Allowing for differences in technique, cardiac, mediastinal and\n hilar contours are unchanged. Pulmonary vascularity cannot be evaluated with\n supine technique. Right basilar opacities are more prominent than on the\n prior study, from enlarged pleural effusion. Left perihilar haziness is\n suggestive of interstitial edema or aspiration. No left sided pleural effusion\n is seen. Osseous structures show interval resection of right sixth rib.\n\n IMPRESSION: 1) Stable cardiomegaly. Supine technique prevents evaluation of\n the pulmonary vessels. 2) Left perihilar haziness could represent unilateral\n interstitial edema or aspiration. 3) Interval resection of right sixth rib.\n 4) Increased right-sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 761171, "text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p ex lap, hartmanns, intubated\n\n REASON FOR THIS EXAMINATION:\n DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Exploratory laparoscopy. Hartmann's. Dyspnea. Intubated.\n\n FINDINGS: Comparison is made to study dated . Since the prior study,\n the patient has been extubated. There is an NG tube extending below the\n diaphgram, tip not visualized. Otherwise, there is no significant interval\n change. There is evidence of a right thoracotomy. There is an 11 mm\n spiculated density in the right upper lobe, suspicious for recurrent\n malignancy, also reported on prior chest CT of .\n\n\n" }, { "category": "Radiology", "chartdate": "2161-04-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 761018, "text": " 8:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: presenting with RLQ pain, r/o bowel obstruction\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with RLQ pain\n REASON FOR THIS EXAMINATION:\n presenting with RLQ pain, r/o bowel obstruction\n ______________________________________________________________________________\n WET READ: 8:55 PM\n perforated cecum, free air\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Right lower quadrant pain, rule out bowel obstruction.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis with oral and intravenous contrast.\n Coronal reconstructions were obtained.\n\n CONTRAST: Oral contrast and 150 cc of intravenous Optiray were administered\n secondary to the patient's history of asthma.\n\n COMPARISON: .\n\n CT OF THE ABDOMEN WITH CONTRAST: There is a large amount of intraperitoneal\n free air. The liver, spleen, adrenals and pancreas are within normal limits.\n There are tiny punctate low attenuation foci in the cortex of the right\n kidney, likely simple renal cysts but too small to characterize. Within the\n left kidney there are similar findings as well as a larger 2 cm exophytic\n simple cyst. The stomach and duodenum appear intact. The small bowel is\n unremarkable. There is no significant retroperitoneal or mesenteric\n adenopathy.\n\n CT OF THE PELVIS WITH CONTRAST: Again there is a large amount of\n intraperitoneal air with two more focal collections, one in the region of the\n cecum and extending along the right paracolic gutter and another more focal\n collection along the left lateral sigmoid. There is no evidence of gas within\n the vasculature and portal venous system. There are scattered air bubbles\n throughout the mesenteric fat. The celiac, SMA, , portal vein and splenic\n vein appear grossly patent. There is a small amount of intraperitoneal and\n pelvic fluid. There is extensive diverticulosis throughout the colon as well\n as a few diverticula in the terminal ileum. There is some mild fat stranding\n around the cecum as well as adjacent to the sigmoid. There is no\n extravasation of either intravenous or oral contrast. The uterus has a\n heterogeneous appearance with some areas of coarse calcification consistent\n with a fibroid uterus.\n\n Bone windows reveal degenerative changes in the lumbar spine. There is a\n small area of lucency in the left iliac of doubtful clinical\n significance. There are no suspicious lytic or blastic lesions.\n\n (Over)\n\n 8:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: presenting with RLQ pain, r/o bowel obstruction\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n There is atelectasis within the right lower lobe as well as a small right\n pleural effusion which may in part be loculated. There is a small nodule in\n the lateral right lung base. This was not present on the prior study and\n follow-up is recommended. The pleural effusion and atelectasis was present\n previously. The left lung base reveals no suspicious nodules and no effusion.\n\n Reformatted images support the above findings.\n\n IMPRESSION:\n 1. Moderate amount of free intraperitoneal air without a definite source. The\n most likely source is a perforated sigmoid diverticulum or perforation\n adjacent to the cecum. With the extensive diverticulosis this likely is the\n underlying cause; however, the patient does have known lung malignancy and a\n metastatic focus is another consideration although less likely. Another\n possibility includes a perforated appendicitis however this is more free air\n than typically seen with perforated appendicitis.\n 2. Mild amount of intraperitoneal free fluid without extravasation of oral\n contrast.\n 3. Small nodule in the right lung base laterally not present on the prior\n film. This may be related to atelectasis or a metastatic focus. Follow-up is\n indicated. Stable atelectasis and right effusion.\n\n The ordering Emergency Room physician, , was notified immediately\n of these findings.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-05-01 00:00:00.000", "description": "Report", "row_id": 1578331, "text": "Resp\nD: pt con't to be intubated this a.m. from surgery. (+) cuff air leak, able to lift head from pillow with propofol off. PCO2 increased ? if @ baseline. On home O2 due to COPD. abd distended and tender to palpation. distal ecchymosis noted. minimal distal S-S drng noted. Stoma pink/red with S-S drainage and some solid fecal material. haviong periods of decreased u/o, concentrated in appearence, SBP occassionally 100. HR SR with occasional PAC. I Ca 1.02\nA: weaned and extubated this a.m. without problem\nn.p. O2 @ 4 L\nLr bolus (250ml) given x 3\nDilaudid PCA started\nDilaudid IV gtt d/c'd\non tapering steroids\nR: doing well post extubation. minimal response from LR bolus'. denies pain despite transient elevation in B/P with activity. Instructed on use of PCA and enc. use. O2 Sat 95-96%. ? transfer to floor later.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-05-04 00:00:00.000", "description": "Report", "row_id": 1578337, "text": "7p-7a: Full assessment in flow sheet.\n\nneuro: Alert and oriented X3. Clear speech. No pain - pain control by PCA. Pt have period of agitation and uncomfortable- relief with reposition and ativan ivp - calmer and less anxious. MAE - strong bilaterally. Good cough and gag reflex. Pt refuse ambulation tonight.\n\ncv: NSR with PAC and PVC rare. No chest pain. Warm, dry, no edema. VSS afebrile.\n\nresp: Lung sound clear in upper lobes, dimish at bases. 2L NC - 94-96%, RR 16-24. Good cough and productive. clear/tan sputum. Chest PT and encourage to deep breath and cough. no sob. regular breathing.\n\ngu/gi: soft distended bowel sound X4. Positive flatus. No stool. no pain on palpation. suture site intact - small ss drainge - transparent dressing. NG tube - +placement, bilous residual. colostomy - beefy red site, edge is dusky. Foley patent - clear yellow urine. Lasix 20 mg ivp - diuresis well.\n\nint: skin intact.\n\nplan: Continue monitor. Transfer to telemtry floor in AM ?\n\n" }, { "category": "Nursing/other", "chartdate": "2161-05-02 00:00:00.000", "description": "Report", "row_id": 1578332, "text": "7P-7a: Full assessment in flow sheet.\n\nneuro: A+oX3. clear speech. MAE - equal and strong. No pain - pain control by PCA (dilaudid). Pt slept on and off. Pt was agitated/frustrated/anxious - yelling and weeping - comfort pt verbally and MD gave order for Ativan .5 mg iv (more comfortable and relax, pt state take xanax at home at night).\n\nresp: Lung sound clear uppers lobes to coarse with dimish at bases. Pt is on 2L NC - 94-98%. Pt was SOB and wheezing - coarse lung sound throughout, \"something stuck in middle of chest\", RR - 18-24.. Chest PT done and encourage to deep breathing and cough, inc O2 - 4L. Productive cough of white, thick sputum. Pt inc SaO2-96-100% RR 16-20.\nFan in room per pt request for more cool air.\n\ncv: NSR with very rare PAC. VSS, afebrile. Warm, dry, no edema.\n\ngu/gi: Soft, distended, and tender abd. Slight pain on palpation - relieve with PCA. No BS X4. No flatus. Colostomy site beefy red to slight dusky -MD aware. Drainage of serosanguios liquid with scant of stool. Colostomy teaching started. Pt state she is no ready to see site. Suture sites intact with ecchyomotic in lower suture site - MD aware - scant drainage - ss. Foley patent - amber/clear urine, output 16-25 cc/hr (Dr. . Mitchele aware). Bolus LR 250 X1, no significant result.\n\nskin: intact. Thoractomy site - Back (r. upper side) - site intact, no drainage, no pain on palpation.\n\nPlan: Monitor gu/gi. Respiratory toileting. AM lab. Possible d/c to floor.\n" }, { "category": "Nursing/other", "chartdate": "2161-05-01 00:00:00.000", "description": "Report", "row_id": 1578330, "text": "4AM-7AM; FULL ASSESSMENT IN FLOW SHEET.\n\n , 62 yrs old caucasian female, transfer from PACU to SICU (cc-687).\n\nallergies: nkda\n\nPMH: COPD, pulmonary hypertension, proxymal afib (cardiovert in past), septal deficit, asthma, emphemsa, thoractomy- biopsy, small cell lung cancer found.\n\nOR procedure: Preforated diverticulitis -> Exp lap, sigmoid colostomy, Hartmann procedure, appendectomy\n\nneuro: Alert and orient X1, Follow commands, mouth words. Open eyes to voice, Good gag reflex. MAE - strong. Propofol drip for sedation. Dilaudid drip for pain.\n\ncv: NSR 80-90 without ectopy. PR - .16 (inverted p), qrs - .12 (BBB), qt- .36 (inverted T). No episode of afib (Pt bounce back and forth from afib to NSR in PACU). warm, dry, no edema. BP 100-125/45-60. Afebrile.\n\nresp: Lung sound rhonchi bilaterally. ET tube inflated in place - SIMV - TV 550, FiO2- 40%, RR 12, . no sob. pt breathing comfortablely.\n\ngu/gi; Abd slight distended. No BS X4. no pain on palpation. abd suture sites - small red drainage with clear tegaderm dressing. NG tube to lwcs - +placement, clear drainage. colostomey - beefy red, no drainage. Foley patent - yellow, clear urine. No bm, no flatus.\n\nint: Skin intact.\n\nPlan: Continue to monitor gu. Hemodynamic monitor. AM lab done. Possible ET d/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-05-02 00:00:00.000", "description": "Report", "row_id": 1578333, "text": "Addendum:\n\nCorrection and update for gu/gi section: Bowel sound present, hypoactive and distant in all 4 quad from 7P-7A. Distended, soft abd - tenderness on palpation. Pain control by dilaudid PCA. no flatus. Colostomy site - beefy red, slight dusky - MD aware - serosangiuos and small stooling. no nausea and vomitting.\n" }, { "category": "Nursing/other", "chartdate": "2161-05-02 00:00:00.000", "description": "Report", "row_id": 1578334, "text": "CONDITION UPDATE\nD.THIS AM,HR=70-80 WITH OCCASSIONAL PAC.KCL ADDED TO PERIPH IV.. PT SCHEDULED TO BE TRANSFERRED THUS A-LINE D/CD. PT SLIGHTLY ANXIOUS RELIEVED WITH TALKING AND OOB TO CHAIR FOR 4 HRS. O2 SAT 97-95.HUO 20-40ML.GOOD ABD PAIN RELIEF WITH DILAUDID.\n BY 1530 PT C/O OF SOB REQUESTING FAN IN ROOM ON HIGH AND BLOWING ON HER..O2 SAT 89-91 WITH RR 20-26.BS WITH EXPIR. WHEEZE. PT NOTED TO HAVE BURSTS OF AF WITH STABLE BP. DR. NOTIFIED. PT ALSO SHORTLY THEREAFTER C/O OF \"PRESSURE \"ACROSS HER UPPER ABD/LOWER CHEST AND HAVING DIFFICULTY SWALLOWING(WHCH WAS TRANGIENTLY RELIEVED WHEN NG FLUSHED WITH NS.PT APPEARED VERY ANXIOUS ALTHOUGH PT DENIED IT.\nA. DR. NOTIFIED OF ALL ABOVE. 12LEAD EKG DONE WITH NO CHANGES PER DR. . PT WAS GIVEN AN ALBUTEROL TX WHICH TRANGIENTLY INCREASED O2 SAT TO 96.. LASIX WAS GIVEN AND CXR DONE...PT ALSO WAS GIVEN 1 DOSE OF ATIVAN TO HELP PT STOP FOCUSING ON NG TUBE AND RELAX.REPEAT LYTES ORDEREDFOR POST DIURESIS.\nR. PT . O2 SAT=94 ON 3L NP . PT IS CALMER.NO FURTHER C/O CHEST/ABD PRESSURE.\n" }, { "category": "Nursing/other", "chartdate": "2161-05-03 00:00:00.000", "description": "Report", "row_id": 1578335, "text": "7P-7A: Full assessment in flow sheet.\n\nneuro: Alert and oriented X3. Calm. Two episode of restlessness and agitation - relief with Ativan 1mg ivp (result - calmer, no c/o of sob). MAE - strong, bilaterally equal. Follow all commands. No pain per pt - pain control by PCA (pt use with activities- movement and coughing). Pt slept most of the night.\n\ncv: NSR with rare PAC, PVC. no chest pain. VSS, afebrile. warm, dry, no edema.\n\nresp: Lung sound clear in upper lobes, dimish at bases. Breathing treatment given, chest PT done, encourage to deep breath and cough. Productive cough - thick, white sputum. no sob, no accessory muscles use. NC 2-3L - SaO2-96-100%, RR 14-24.\n\ngu/gi: Soft distend abd with hypoactive BS X4. Suture site - intact with small drainage. Colostomy - beefy red with small stooling and small red drainage. foley patent - clear yellow urine >28 cc/hr. NG tube - +placement, bilious drainage.\n\nskin; Intact.\n\nNo allergic reaction to antibiotic.\n\nExplain all procedures and comfort pt verbally.\n\nplan: Continue to monitor. Am lab. Transfer to floor in AM.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-05-03 00:00:00.000", "description": "Report", "row_id": 1578336, "text": "CONDITION UPDATE\nD. 62 YR OLD FEMALE WITH NKA.PMH= HBP,CAD,HX AFIB WITH CARDIOVERSION IN PAST.COPD ON HOME O2.,SM CELL CA IN R LUNG FOR WHICH PT HAD OPEN THORACOTOMY 1 WK PTA.\n PT ADMITTED WITH HX OF 1 WK RLQ ABD PAINAND NO BM..PERFORATED DIVERTICULITIS. EXPL. LAP WITH SIGMOID COLOSTOMY, PROCEDURE,AND APPENDECTOMY..PT REMAINED INTUBATED AND SEDATED OVERNITE.\n PT DUE TO BE TRANSFERRED BUT DESATED TO 89 WITH MARGINAL UO AND HIGH ANXIETY. CXR=SM FAILURE. DIURESIS SUCCESSFUL AND ATIVAN FOR ANXIETY HELPFUL TO RELIEVE HYPOXIA. O2 SAT=93 ON 2L NP ONLY.\n AFEBRILE,SR WITH OCCASSIONAL PAC,RR=13-20,O2 SAT MAINTAINED AT 93-95 ON 2L NP. BP STABLE.\n HUO DOWN TO 20-30ML/HR WITH LAST 24 HR FLUID BALANCE REMAINING SL POS. DESPITE YESTERDAY'S DIURESIS.THUS LASIX GIVEN WITH SUCCESSFUL DIURESING.IVF AT 50ML/HR.\n NO ACUTE ANXIETY EPISODES HOWEVER PT REQUESTED ATIVAN AT Q 6 HR INTERVALS TO ENABLE HER TO TOLERATE THE FEELING OF NG IN BACK OF THROAT.\n PT USING DILAUDID SUCCESSFULLY AND ABLE TO COUGH WELL AND AMBULATE WITH MINIMAL DISCOMFORT AND NO O2 PER PT..\n MORE ACTIVE BOWEL SOUNDS AND COLOSTOMY PRODUCING FLATUS ONLY TODAY.\n ABD INCISION D&I. DILAUDID PCA SUCCESSFUL IN RELIEVING PAIN.\nA. AWAIT TELEMETRY BED WHEN AVAIABLE\nR. STABLE\n" }, { "category": "ECG", "chartdate": "2161-04-30 00:00:00.000", "description": "Report", "row_id": 128395, "text": "Sinus rhythm\n- supraventricular extrasystoles\nIncomplete right bundle branch block\nRight ventricular hypertrophy\nInferior and lateral ST-T changes suggest myocardial injury/ischemia\nSince last ECG, no significant change\n\n" } ]

[ { "category": "Physician ", "chartdate": "2111-10-11 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 340787, "text": "Chief Complaint: right hand numbness\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 87 yr old female, hx HTN, TIA 1 year ago tx with coumadin\n This AM, right hand was numb, resolved within hours\n This afternoon had episode of slurred speech ?expressive aphasia.\n Approx 4 days ago had first episode of hand numbness. Also, over past 5\n days, intermittent headache\n Brought to , had CT head revealed acute on chronic\n subdural.\n Because of mass effect, was treated with Decadron.\n Transferred to ED. SBP in ED as high as 205, now 140s-180. Pt\n c/o substernal pain, no radiation, no diaphoresis. Pain lasted ~ 4\n min. Pt received s/l NTG. All symptoms currently resolved. CT head\n repeated and pt seen by neurosurg\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Nexium, fosinopril 40, atenolol 50, diovan, isordil 30, lasix 40,\n vesicare 5, verapamil 180, fosamax, coumadin, lipitor, ca, mvi\n Past medical history:\n Family history:\n Social History:\n HTN\n ?TIA 1 year ago\n Pacemaker\n GERD\n Mother and brother had ?CAD. Son had a brain tumor.\n Occupation: retired\n Drugs: no\n Tobacco: never\n Alcohol: 1 drink /wk\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: Chest pain, occasionally at rest\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea,\n Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Heme / Lymph: on coumadin for ?TIA\n Neurologic: Headache, H/a past 5 d\n Allergy / Immunology: unknown\n Signs or concerns for abuse : No\n Flowsheet Data as of 10:54 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 79 (66 - 89) bpm\n BP: 125/63(79) {122/63(79) - 152/88(102)} mmHg\n RR: 21 (10 - 26) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,050 mL\n PO:\n TF:\n IVF:\n 527 mL\n Blood products:\n 523 mL\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 900 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Normal, no facial droop, no gross\n weakness\n Labs / Radiology\n 212 K/uL\n 29.2 %\n 10.5 g/dL\n 135 mg/dL\n 0.9 mg/dL\n 22 mg/dL\n 23 mEq/L\n 107 mEq/L\n 3.7 mEq/L\n 143 mEq/L\n 6.9 K/uL\n [image002.jpg]\n 09:25 PM\n WBC\n 6.9\n Hct\n 29.2\n Plt\n 212\n Cr\n 0.9\n Glucose\n 135\n Other labs: PT / PTT / INR:19.9/28.5/1.9, Ca++:8.9 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Imaging: CT head showed 1.8 cm SDH likely chronic with mild mass effect\n but no midline shift, no herniation\n Assessment and Plan\n 87 yr old with sx of hand numbness and ? expressive aphasia, resolved.\n Likely TIA. Confounded SDH on CT of unknown onset.\n 1. SDH\n INR being reversed with vit K and FFP. CT head to be\n repeated in AM. Dilantin per neurosurgery. Try to keep SBP 140-160\n range. Neurochecks.\n 2. TIA symptoms\n unlikely due to SDH, no signs of infection.\n Will check CXR.\n 3. chest pain\n likely angina, now resolved. ECG changes need to\n be compared to older ECGs (will try to obtain from ). R/o for\n MI. Obtain echo in AM\n 4. HTN\n Anemia\n MCV 85 with RDW 15. R/o iron deficiency\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 08:00 PM\n 18 Gauge - 08:00 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Communication: ICU consent signed\n Code status: Full code\n Disposition:\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2111-10-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 340790, "text": "Chief Complaint: right hand numbness, chest pressure\n HPI:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. Though we do not have records from \n ED, she was treated with decadron and then transferred to due to\n patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reports that the pain\n has come on at rest and not with exertion per se.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies: NKDA\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n fosinopril 40 mg daily\n atenolol 50 mg daily\n diovan 320 mg daily\n isosorbide 30 mg daily\n lasix 40 mg daily\n nexium 40 mg daily\n vesicare 5 mg daily\n verapamil 180 mg daily\n fosamax 70 mg weekly\n coumadin 5 mg daily\n lipitor 40 mg daily\n calcium 600 mg \n MVI daily\n Past medical history:\n Family history:\n Social History:\n * Hypertension\n * s/p pacemaker (\"passing out\" spells, not sure indication)\n * in \n Mother and brother with \"heart problems,\" thinks CHF. Son died in 30s\n from brain tumor.\n Occupation: Retired, prior homemaker & worked in shop.\n Drugs: Denies.\n Tobacco: Never smoker.\n Alcohol: One drink per week.\n Other: Lives with daughter. Widowed.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: Chest pain, No(t) Palpitations, Edema, No(t) Orthopnea,\n Per HPI, ankle edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, Constipation,\n occasional constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: Coagulopathy, On coumadin\n Neurologic: Numbness / tingling, Headache, HA X 5 days, intermittent\n Flowsheet Data as of 12:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 79 (66 - 89) bpm\n BP: 147/96(109) {122/63(79) - 152/96(109)} mmHg\n RR: 21 (10 - 26) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,063 mL\n 1 mL\n PO:\n TF:\n IVF:\n 540 mL\n 1 mL\n Blood products:\n 523 mL\n Total out:\n 240 mL\n 0 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 823 mL\n 1 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n VS - Temp 97.4 F, BP 152/77,HR 73, R 10, O2-sat 97% RA\n GENERAL - alert, pleasant female, lying in bed in no distress\n HEENT - PERRL, EOMI. MMM, tongue midline, symmetric palate elevation.\n NECK - no lymphadenopathy, JVP at 7 cm\n LUNGS - clear bilaterally without any wheezes, crackles, or rhonchi\n HEART - RRR, systolic murmur at the LLSB\n ABDOMEN - soft, normoactive bowel sounds, nontender to palpation\n EXTREMITIES - 1+ pitting edema bilaterally, DP pulses 2+ bilaterally\n NEURO - A&O X 3. CN II-XII intact. Strength 5/5 bilateral biceps,\n triceps, hand grip, intrinsic hand muscles, hip flexors, ankle\n dorsiflexion & plantarflexion. DTRs 2+ bilaterally at biceps. Sensation\n to light touch intact bilateral upper & lower extremities. No pronator\n drift. Finger to nose testing intact., Toes equivocal.\n Labs / Radiology\n 212 K/uL\n 10.5 g/dL\n 135 mg/dL\n 0.9 mg/dL\n 22 mg/dL\n 23 mEq/L\n 107 mEq/L\n 3.7 mEq/L\n 143 mEq/L\n 29.2 %\n 6.9 K/uL\n [image002.jpg]\n \n 2:33 A9/7/ 09:25 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.9\n Hct\n 29.2\n Plt\n 212\n Cr\n 0.9\n TropT\n 0.08\n Glucose\n 135\n Other labs: PT / PTT / INR:19.9/28.5/1.9, CK / CKMB /\n Troponin-T:72/4/0.08, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Studies:\n CT HEAD: L convexity subdural measuring 1.8 cm from the inner table,\n likely chronic with mild mass effect and no midline shift or\n herniation. (prelim read)\n EKG (1400): A-V paced, no acute ST changes\n EKG (1635): sinus rhythm at 70, LAD, LVH, diffuse symmetric T wave\n inversions in V3-6, biphasic T wave in V2, inverted T waves in II, III,\n aVF\n EKG (2200): sinus rhythm at 80, LAD, symmetric inverted T waves in\n V3-6, biphasic T wave in V2, inverted T waves in II, III, aVF0\n Assessment and Plan\n 87 y/o woman with hypertension, prior admitted with right hand\n numbness in setting of subdural hemorrhage.\n #. Subdural hemorrhage: Small area of acute hemorrhage in\n chronic-appearing subdural per imaging. No residual deficits per my\n exam on arrival to MICU.\n - Hold all anticoagulation\n - INR goal 1, check q4h, use FFP prn\n - vitamin K 10 mg PO X 1 to reverse INR\n - Q2h neuro checks\n - Appreciate Neurosurgery and Neurology input\n - dilantin load tonight (1000 mg) then 100 mg TID per NSG recs\n - HOB elevated\n - repeat head CT in the morning\n - attempt to obtain records from ED\n - SSI for euglycemia\n # Chest pain: Patient did have one episode of chest pain in the ED,\n though now is pain-free. EKG does have symmetric T wave inversions,\n though difficult to assess given lack of baseline EKG and fact that\n prior EKG was paced. T wave inversions could reflect intracranial\n pathology though certainly ischemia should be ruled out.\n - monitor closely\n - cycle cardiac enzymes\n - serial EKGs\n - ECHO in the AM to assess wall motion\n - obtain old EKG from ED or PCP in AM\n - No ASA due to SDH\n - No BB currently due to relative hypotension\n # ? : Neurology consultant believes symptoms compatible with lacunar\n infarct, will be difficult to see on CT. Cannot get MRI due to\n pacemaker. UA negative for infection though certainly infection could\n cause re-presentation of neuro deficits.\n - risk stratification with A1c, lipids in AM\n - hold any anticoagulation as per above\n - consider CTA after acute bleed addressed (per Neurology)\n - no sign of infection but will send blood cx with AM labs\n #. Hypertension: Hypertensive on arrival, now with BPs 120s while\n resting comfortably.\n - Hold all antihypertensives\n - consider BB (due to ? ischemia) if SBP > 185\n #. Anemia: Baseline Hct unknown. Add on iron studies\n # GERD: Continue ppi.\n # Osteoporosis: Hold fosamax for now, will resume when clinically\n stable.\n #. FEN - NPO for now, replete lytes prn\n #. PPx - pneumoboots, PPI (home regimen), bowel meds prn\n # Access: 2 PIVs\n #. Code - Full, confirmed with patient, though she would not like to be\n on life support if there is no chance of recovery.\n # Communication: With patient and family. HCP is daughter per\n patient.\n #. Dispo - MICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI (home regimen)\n VAP: HOB elevated, not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2111-10-12 00:00:00.000", "description": "Generic Note", "row_id": 340820, "text": "TITLE:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. Though we do not have records from \n ED, she was treated with decadron and then transferred to due to\n patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reports that the pain\n has come on at rest and not with exertion per se.\n" }, { "category": "Nursing", "chartdate": "2111-10-12 00:00:00.000", "description": "Generic Note", "row_id": 340821, "text": "TITLE:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. Though we do not have records from \n ED, she was treated with decadron and then transferred to due to\n patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reports that the pain\n has come on at rest and not with exertion per se.\n #. Subdural hemorrhage: Small area of acute hemorrhage in\n chronic-appearing subdural per imaging. No residual deficits per my\n exam on arrival to MICU.\n - Hold all anticoagulation\n - INR goal 1, check q4h, use FFP prn\n - vitamin K 10 mg PO X 1 to reverse INR\n - Q2h neuro checks\n - Appreciate Neurosurgery and Neurology input\n - dilantin load tonight (1000 mg) then 100 mg TID per NSG recs\n - HOB elevated\n - repeat head CT in the morning\n - attempt to obtain records from ED\n - SSI for euglycemia\n # Chest pain: Patient did have one episode of chest pain in the ED,\n though now is pain-free. EKG does have symmetric T wave inversions,\n though difficult to assess given lack of baseline EKG and fact that\n prior EKG was paced. T wave inversions could reflect intracranial\n pathology though certainly ischemia should be ruled out.\n - monitor closely\n - cycle cardiac enzymes\n - serial EKGs\n - ECHO in the AM to assess wall motion\n - obtain old EKG from ED or PCP in AM\n - No ASA due to SDH\n - No BB currently due to relative hypotension\n # ? : Neurology consultant believes symptoms compatible with lacunar\n infarct, will be difficult to see on CT. Cannot get MRI due to\n pacemaker. UA negative for infection though certainly infection could\n cause re-presentation of neuro deficits.\n - risk stratification with A1c, lipids in AM\n - hold any anticoagulation as per above\n - consider CTA after acute bleed addressed (per Neurology)\n - no sign of infection but will send blood cx with AM labs\n #. Hypertension: Hypertensive on arrival, now with BPs 120s while\n resting comfortably.\n - Hold all antihypertensives\n - consider BB (due to ? ischemia) if SBP > 185\n" }, { "category": "Nursing", "chartdate": "2111-10-13 00:00:00.000", "description": "Generic Note", "row_id": 341111, "text": "TITLE:\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n No deficit noted from neuro checks. Denies headache. Hand grasps equal.\n Smile- no drooping seen. Moving all extremities. Alert and ox3. Follows\n commands.\n Action:\n Neuro checks done q2hrs. Followed by Neuro-.\n Response:\n No deficits observed. No change seen on head CT.\n Plan:\n Neuro checks q2hrs.\n Chest pain\n Assessment:\n Denied CP. AV paced w/ rare PVC\ns. INR 1.4, CPK 175\n Action:\n EKG done after noticing that herCPK is elevated . . Troponin added to\n am labs. Will follow up.\n Response:\n Continued to deny CP. Repeat INR 1.4. Troponin Up to 0.15\n Plan:\n Assess CP. Monitor labs. Cardiology follow up.\n Dyspnea (Shortness of breath)\n Assessment:\n O2 sats decreased to high 80\ns. Subsequently, desated to 88% w/ turns\n or activity. LS clear anteriorly, diminished bases w/ crackles\n way\n up.\n Action:\n Intern aware, O2 increased to face tent @ 70% ,increased to 100 &. IV\n Lasix 40 mgs given. HOB>45degrees. LS monitored.\n Response:\n O2 sats 93-98% on face mask @ 100 % LS improved slightly throughout\n day. Continued to desat w/ activity.\n Plan:\n Monitor LS/ o2 sats/ RR. Nebs as needed. Wean o2 as tolerated. Will\n monitor urine output & lytes.\n" }, { "category": "Nursing", "chartdate": "2111-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341240, "text": "Synopsis per prior nursing note:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reported that the pain\n has come on at rest and not with exertion per se.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n No deficit noted from neuro checks. Denies headache. Hand grasps equal.\n Smile- no drooping seen. Moving all extremities. Alert and ox3. Follows\n commands.\n Action:\n Neuro checks done q4hrs. Followed by Neuro-.\n Response:\n No deficits observed. Neuro- recommended SBP >160 but aware that\n SBP range has been 120\ns to 140\n Plan:\n Neuro checks q4hrs. Monitor BP.\n Chest pain\n Assessment:\n Denied CP. AV paced w/ rare PVC\ns. INR 1.4. Trop .15 (.09).\n Action:\n Daily EKG\ns done. Cardiology following. Continued on Lopressor 12.5mg.\n Response:\n Continued to deny CP. Cardiac ECHO showed EF 30% and multiple valve\n regurgitation.\n Plan:\n Assess CP. Monitor labs. Monitor daily troponin. Daily EKG\n Dyspnea (Shortness of breath)\n Assessment:\n LS clear anteriorly, diminished bases w/ crackles\n way up. Continues\n to desat to high 80\ns when turned. Able to stand and pivot to chair w/o\n desating.\n Action:\n Oxygen titrated for o2 sats >93%. HOB>45degrees. LS monitored.\n Response:\n O2 sats 93-98% on NC @ 4-6L. LS improved slightly throughout day.\n Continued to desat w/ activity.\n Plan:\n Monitor LS/ o2 sats/ RR. Nebs as needed. Wean o2 as tolerated\n" }, { "category": "Nursing", "chartdate": "2111-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341308, "text": "Synopsis per prior nursing note:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reported that the pain\n has come on at rest and not with exertion per se.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam WNL, see q 4 hr neuro checks. Denies HA, numbness/tingling\n in extremities. Speech clear.\n Action:\n Q 4 hr neuro checks. HOB ^^ 45 degrees.\n Response:\n Neuro exam WNL.\n Plan:\n Neuro checks q 4 hrs per neuro surgery. HOB^^ 45 degrees.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n VSS, NBP 130s-150s/60s-80s. Vpaced with occ PVCs. Denies CP, SOB.\n Action:\n CPKs sent with AM labs. Baby ASA started. Lopressor given.\n Response:\n Remains symptom free. VSS.\n Plan:\n Lopressor, ASA, lipitor. Cycle CPKs as directed. Hold anticoagulation\n in setting of SDH.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Breath sounds clear, diminished at bases. Sats 94-97% 5L NC. No\n DOE/SOB.\n Action:\n AM CXR pending.\n Response:\n No S/S pulmonary edema.\n Plan:\n Check AM CXR. Lasix prn. Follow lytes with diuresis.\n" }, { "category": "Physician ", "chartdate": "2111-10-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 341395, "text": "Chief Complaint: SDH / acute MI\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 Cardiology and neurosurgery consults continue to follow.\n ASA begun after discussion with neurosurg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n statin, SQI, PPI, vit K, DPH, ASA, Lopressor\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:34 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: 36.8\nC (98.2\n HR: 88 (75 - 96) bpm\n BP: 144/83(97) {106/36(75) - 153/89(105)} mmHg\n RR: 20 (20 - 29) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 62 Inch\n Total In:\n 859 mL\n 173 mL\n PO:\n 360 mL\n 60 mL\n TF:\n IVF:\n 499 mL\n 113 mL\n Blood products:\n Total out:\n 1,710 mL\n 220 mL\n Urine:\n 1,710 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -851 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), soft\n murmurs; no S3\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: Crackles : basilar; improved)\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 10.6 g/dL\n 196 K/uL\n 114 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.8 %\n 11.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n 10:45 AM\n 04:12 AM\n 04:45 PM\n 02:50 AM\n WBC\n 6.9\n 7.4\n 13.7\n 11.5\n Hct\n 29.2\n 28.1\n 31.2\n 33.5\n 29.8\n Plt\n 96\n Cr\n 0.9\n 0.8\n 0.9\n 0.9\n 0.7\n TropT\n 0.08\n 0.09\n 0.15\n 0.10\n 0.10\n Glucose\n 135\n 154\n 144\n 151\n 114\n Other labs: PT / PTT / INR:15.0/28.3/1.3, CK / CKMB /\n Troponin-T:109/5/0.10, ALT / AST:106/162, Alk Phos / T Bili:106/0.6,\n Differential-Neuts:85.9 %, Lymph:10.3 %, Mono:2.8 %, Eos:0.8 %,\n Albumin:3.7 g/dL, LDH:329 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:1.2\n mg/dL\n Imaging: CXR: effusions, pacemaker\n Assessment and Plan\n 87 y/o woman with subdural hematoma and possible TIA as well as what\n appears to be an acute MI with substantial heart failure. TIA symptoms\n have resolved but SDH persists. Her hypoxemia has improved but not\n resolved with diuresis. Current problems include:\n\n SUBDURAL HEMORRHAGE (SDH)\n continue vitamin K\n avoid warfarin until cleared by neurosurg\n follow INR. At this point (given pulmonary edema), risks of\n FFP outweigh benefits barring further changes in SDH or increases in\n INR\n surgical management per neurosurgery. At present, the plan\n is to follow with intermittent CTs and neuro checks. If her neurologic\n status declines she would need more urgent intervention. However, the\n risks of surgical intervention are high in the peri-infarct period and\n we will defer as long as feasible. Right now, I agree with\n neurosurgery and cardiology that the risks of surgical intervention\n outweigh benefits.\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n management limited by SDH\n Beta blockade. Rhythm is not clear on telemetry right now\n (a-sensed v-paced vs. v-paced only). Will check 12 lead and discuss\n with cardiology.\n Begin ACEI when beta blockade maximized or after a week\n (when VT risk is lower)\n Diurese gently today\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n diuresis as above\n beta blockade\n see discussion above\n ACEI\n see discussion above\n Anemia\n follow\n ICU Care\n Nutrition: oral diet\n Glycemic Control: well-controlled\n Lines:\n 20 Gauge - 10:00 PM\n 22 Gauge - 10:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2111-10-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341398, "text": "Chief Complaint:\n 24 Hour Events:\n -low urine output overnight\n -neurology and neurosurgery ok with ASA 81 - started\n -neuro thinks TIA vs seizure with TIA much more likely\n -cards discussed with patient the need for max medical management\n before even considering the longterm possibility of burr hole placement\n -negative 900ccs in past 24 hours\n -took nasal cannula off and desat to mid-80s\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 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 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 81 (75 - 102) bpm\n BP: 153/85(102) {106/36(75) - 153/89(105)} mmHg\n RR: 25 (20 - 29) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Height: 62 Inch\n Total In:\n 859 mL\n 140 mL\n PO:\n 360 mL\n 60 mL\n TF:\n IVF:\n 499 mL\n 80 mL\n Blood products:\n Total out:\n 1,710 mL\n 130 mL\n Urine:\n 1,710 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -851 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 5 L\n SpO2: 96%\n Physical Examination\n Gen: Pleasant, alert female in NAD\n Neck: JVD 8 cm\n CV: soft systolic murmur in LUSB, RRR\n Lungs: crackles L ( lung fields) >R (basilar)\n Abd: soft, NT/ND\n Ext: no CCE\n Neuro: CN 2-12 grossly intact, 5/5 strength by bed exam in all four\n extremities, sensation intact\n Labs / Radiology\n 196 K/uL\n 10.6 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.8 %\n 11.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n 10:45 AM\n 04:12 AM\n 04:45 PM\n 02:50 AM\n WBC\n 6.9\n 7.4\n 13.7\n 11.5\n Hct\n 29.2\n 28.1\n 31.2\n 33.5\n 29.8\n Plt\n 96\n Cr\n 0.9\n 0.8\n 0.9\n 0.9\n 0.7\n TropT\n 0.08\n 0.09\n 0.15\n 0.10\n 0.10\n Glucose\n 135\n 154\n 144\n 151\n 114\n Other labs: PT / PTT / INR:16.1/26.6/1.4, CK / CKMB /\n Troponin-T:109/5/0.10, ALT / AST:106/162, Alk Phos / T Bili:106/0.6,\n Differential-Neuts:85.9 %, Lymph:10.3 %, Mono:2.8 %, Eos:0.8 %,\n Albumin:3.7 g/dL, LDH:329 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:1.2\n mg/dL\n Assessment and Plan\n 87 y/o woman with subdural hematoma and possible TIA vs partial\n seizures as well as what appears to be an acute MI with substantial\n heart failure. TIA symptoms have resolved but SDH persists. She also\n has substantial hypoxemia in the setting of multiple units of FFP and\n newly diagnosed systolic CHF. Current problems include:\n # SUBDURAL HEMORRHAGE (SDH)\n Stable. INR goal 1. Currently 1.3. Very\n high risk surgical candidate per cards\n prefer medical management.\n - Vitamin K 10mg PO today\n - surgical management electively or in the case of acute\n decompensation\n - neuro checks to q4hours\n - continue dilantin\n f/u with neurology when to check levels\n - f/u neurosurg, neurology recs\n - head CT or if pt acutely decompensates\n # MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI) c/b cardiogenic\n pulmonary edema\n Troponins now trending down.\n - management limited by SDH\n - beta blockade. Will tolerate SBPs down to 110 for now\n - increase ASA to 325 mg ok by neuro and neurosurg\n - diurese gently today to try to decrease myocardial O2 demand\n and improve pulmonary edema (-500 goal)\n - per cards, would like to add lisinopril 5mg if BP will\n tolerate\n assess BP tomorrow to determine if BP will tolerate\n - lasix 40mg IV today for goal -500 mls\n # TIA vs Seizure\n Aside from RUE weakness, sx largely resolved.\n - f/u neurosurgery, neurology recs\n - continue dilantin\n - consider CTA as per neuro for further characterization of ?\n ischemia in setting of inability to do MR b/c pacer\n # Anemia\n Fe studies normal, normocytic, stable.\n - follow Hcts\n # GERD\n - PPI\n # Osteoarthritis\n stable\n ICU Care\n Nutrition: Heart healthy diet\n Glucose control\n SSI\n PPX\n Dvt\n pneumoboots, PPI\n Communication\n daughter and granddaughter\n FULL CODE\n Appropriate for transfer out of MICU to floor team\n" }, { "category": "Physician ", "chartdate": "2111-10-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 340918, "text": "24 Hour Events:\n -INR: 2.3\n 1.9\n 1.5 s/p 4 un FFP and vit K. Getting another un FFP\n this am\n - am head CT per neurosurg\n -Tpn continue to rise\n -Cards believe that EKG may be to memory T waves, however, given\n that she has the changes in the distribution of the lateral leads. She\n can be ruled out for MI, however, given her head bleed, she is unable\n to tolerate the treatment- heparin. At this time, conservative\n management with lipid panel and HbA1c.\n -Neuro following as well\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 61 (60 - 90) bpm\n BP: 127/59(76) {118/59(62) - 152/96(109)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,251 mL\n 699 mL\n PO:\n TF:\n IVF:\n 728 mL\n 132 mL\n Blood products:\n 523 mL\n 567 mL\n Total out:\n 240 mL\n 150 mL\n Urine:\n 240 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,011 mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 215 K/uL\n 9.9 g/dL\n 154 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 109 mEq/L\n 145 mEq/L\n 28.1 %\n 7.4 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n WBC\n 6.9\n 7.4\n Hct\n 29.2\n 28.1\n Plt\n 212\n 215\n Cr\n 0.9\n 0.8\n TropT\n 0.08\n 0.09\n Glucose\n 135\n 154\n Other labs: PT / PTT / INR:17.0/27.9/1.5, CK / CKMB /\n Troponin-T:87/4/0.09, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.0 mg/dL\n Ck CKMB Tp\n 4am 87 0.09\n 9:30pm 72 4 0.08\n 2:30pm 40 <0.01\n Assessment and Plan\n 87 y/o woman with hypertension, prior TIA admitted with right hand\n numbness, resolved, in setting of acute on chronic subdural hemorrhage.\n #. Subdural hemorrhage: Small area of acute hemorrhage in\n chronic-appearing subdural per imaging. No residual deficits per exam\n on arrival to MICU.\n - Holding all anticoagulation\n - INR goal 1 (1.4 per neuron), check q4h. On 5^th unit FFP. Post\n transfusion coags.\n -rec\nd vitamin K 10 mg PO X 1\n - Q2h neuro checks\n - Recheck HCT later today\n - Appreciate Neurosurgery and Neurology input\n - Neurosurg would like pt medically cleared prior to going to OR. Will\n consult cards to help clear pt given that she will equivocally rule in\n with elev troponins\n - dilantin load tonight (1000 mg) then 100 mg TID per NSG recs. Side\n effect of dilantin is hypotension which may explain her relative\n hypotension\n - elevated\n - repeat head CT this am\n - SSI for euglycemia\n # Chest pain: Patient did have one episode of chest pain in the ED,\n though now is pain-free. EKG does have symmetric T wave inversions,\n though difficult to assess given lack of baseline EKG and fact that\n prior EKG was paced. T wave inversions could reflect intracranial\n pathology though certainly ischemia should be ruled out.\n - CEs x 3. Troponins elevated at 0.09\n - serial EKGs\n - ECHO in the AM to assess wall motion- RN report- elevated\n PA pressures. Need to f/up final read.\n - No anticoagulation\n - No BB currently due to relative hypotension\n - Consult cards for medical clearance in light of elev troponins and\n what will most likely be echo abnormalities\n # ? TIA: Neurology consultant believes symptoms compatible with lacunar\n infarct, will be difficult to see on CT. Cannot get MRI due to\n pacemaker. UA negative for infection though certainly infection could\n cause re-presentation of neuro deficits.\n - risk stratification with A1c, lipids in AM. Labs pending\n - hold any anticoagulation as per above\n - consider CTA after acute bleed addressed (per Neurology)\n - no sign of infection but will sent blood cx with this morning\ns labs\n #. Hypertension: Hypertensive on arrival, now with BPs 120s while\n resting comfortably.\n - Hold all antihypertensives\n - consider BB (due to ? ischemia) if SBP > 185\n #. Anemia: Baseline Hct unknown. Add on iron studies. Will guiac next\n stool.\n # GERD: Continue ppi.\n # Osteoporosis: Hold fosamax for now, will resume when clinically\n stable.\n #. FEN - NPO for now, replete lytes prn\n #. PPx - pneumoboots, PPI (home regimen), bowel meds prn\n # Access: 2 PIVs\n #. Code - Full, confirmed with patient, though she would not like to be\n on life support if there is no chance of recovery.\n # Communication: With patient and family. HCP is daughter per\n patient.\n #. Dispo - MICU for now\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2111-10-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 340915, "text": "Chief Complaint: subdural hematoma\n HPI:\n 24 Hour Events:\n EKG - At 10:17 PM\n Has some ongoing headache. Echo done; results pending.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n DPH, PPI, SQI, statin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 64 (60 - 90) bpm\n BP: 102/80(85) {102/59(62) - 152/96(109)} mmHg\n RR: 16 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,251 mL\n 1,011 mL\n PO:\n TF:\n IVF:\n 728 mL\n 164 mL\n Blood products:\n 523 mL\n 847 mL\n Total out:\n 240 mL\n 400 mL\n Urine:\n 240 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,011 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Wheezes : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal, CN II-XII functionally\n intact\n Labs / Radiology\n 9.9 g/dL\n 215 K/uL\n 154 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 109 mEq/L\n 145 mEq/L\n 28.1 %\n 7.4 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n WBC\n 6.9\n 7.4\n Hct\n 29.2\n 28.1\n Plt\n 212\n 215\n Cr\n 0.9\n 0.8\n TropT\n 0.08\n 0.09\n Glucose\n 135\n 154\n Other labs: PT / PTT / INR:17.0/27.9/1.5, CK / CKMB /\n Troponin-T:87/4/0.09, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 87 y/o woman with subdural hematoma and possible TIA. TIA symptoms\n have resolved but SDH persists. She also has substantial hypoxemia in\n the setting of multiple units of FFP. Current problems include:\n Subdural hematoma\n Abnormal EKG and slightly positive troponin (neurogenic vs.\n cardiac)\n Normotense in the setting of history of hypertension\n Anemia\n Hypoxemia\n We will continue seizure prophylaxis. She will likely need SDH\n drainage per neurosurgery. We will follow up the echocardiogram report\n and ask cardiology to comment on risk-reducing maneuvers.\n Her hypoxemia is also concerning. Most likely related to FFP: we will\n check a CXR to start the evaluation.\n For her anemia, we will guaiac stool and follow serial Hcts.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control: follow FSBS\n Lines:\n 20 Gauge - 08:00 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 min\n" }, { "category": "Physician ", "chartdate": "2111-10-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341087, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Neurosurgery: Burr hole when cleared by cards, as high-risk per cards\n will consider in AM\n Cardiology: Patient high-risk given evidence of active ischemia.\n Management restricted bleeding risk\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 84 (61 - 94) bpm\n BP: 155/80(98) {102/58(74) - 155/88(103)} mmHg\n RR: 28 (11 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,250 mL\n 154 mL\n PO:\n 100 mL\n TF:\n IVF:\n 303 mL\n 154 mL\n Blood products:\n 847 mL\n Total out:\n 900 mL\n 75 mL\n Urine:\n 900 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 350 mL\n 79 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 255 K/uL\n 11.6 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 109 mEq/L\n 143 mEq/L\n 33.5 %\n 13.7 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n 10:45 AM\n 04:12 AM\n WBC\n 6.9\n 7.4\n 13.7\n Hct\n 29.2\n 28.1\n 31.2\n 33.5\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TropT\n 0.08\n 0.09\n Glucose\n 135\n 154\n 144\n Other labs: PT / PTT / INR:16.1/26.6/1.4, CK / CKMB /\n Troponin-T:175/4/0.09, ALT / AST:106/162, Alk Phos / T Bili:106/0.6,\n Differential-Neuts:85.9 %, Lymph:10.3 %, Mono:2.8 %, Eos:0.8 %,\n Albumin:3.7 g/dL, LDH:329 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Fluid analysis / Other labs: iron studies, stim test, dilantin\n Imaging: head CT\n Echo\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 22 Gauge - 10:00 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": "2111-10-13 00:00:00.000", "description": "Generic Note", "row_id": 341093, "text": "TITLE:\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n No deficit noted from neuro checks. Denies headache. Hand grasps equal.\n Smile- no drooping seen. Moving all extremities. Alert and ox3. Follows\n commands.\n Action:\n Neuro checks done q2hrs. Followed by Neuro-.\n Response:\n No deficits observed. No change seen on head CT.\n Plan:\n Neuro checks q2hrs.\n Chest pain\n Assessment:\n Denied CP. AV paced w/ rare PVC\ns. INR 1.4, CPK 175\n Action:\n EKG\ns done . Cardiology following. Troponin added to am labs. Will\n follow up.\n Response:\n Continued to deny CP. Repeat INR 1.4.\n Plan:\n Assess CP. Monitor labs.\n Dyspnea (Shortness of breath)\n Assessment:\n o2 sats decreased to high 80\ns. Subsequently, desated to 88% w/ turns\n or activity. LS clear anteriorly, diminished bases w/ crackles\n way\n up.\n Action:\n O2 increased to face tent @ 70%. Albuterol neb treatment given.\n HOB>45degrees. LS monitored.\n Response:\n O2 sats 93-98% on face mask @ 70%. LS improved slightly throughout day.\n Continued to desat w/ activity.\n Plan:\n Monitor LS/ o2 sats/ RR. Nebs as needed. Wean o2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2111-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341291, "text": "Synopsis per prior nursing note:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reported that the pain\n has come on at rest and not with exertion per se.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n No deficit noted from neuro checks. Denies headache. Hand grasps equal.\n Smile- no drooping seen. Moving all extremities. Alert and ox3. Follows\n commands.\n Action:\n Neuro checks done q4hrs. Followed by Neuro-.\n Response:\n No deficits observed. Neuro- recommended SBP >160 but aware that\n SBP range has been 120\ns to 140\n Plan:\n Neuro checks q4hrs. Monitor BP.\n Chest pain\n Assessment:\n Denied CP. AV paced w/ rare PVC\ns. INR 1.4. Trop .15 (.09). K 2.9. Phos\n 1.1.\n Action:\n Daily EKG\ns done. Cardiology following. Continued on Lopressor 12.5mg.\n Given 40mEq potassium PO and 2pk of neutral-phos.\n Response:\n Continued to deny CP. Cardiac ECHO showed EF 30% and multiple valve\n regurgitation.\n Plan:\n Assess CP. Monitor labs. Monitor daily troponin. Daily EKG\ns. Given IV\n dose of potassium when received from pharmacy. Monitor lytes.\n Dyspnea (Shortness of breath)\n Assessment:\n LS clear anteriorly, diminished bases w/ crackles\n way up. Continues\n to desat to high 80\ns when turned. Able to stand and pivot to chair w/o\n desating.\n Action:\n Oxygen titrated for o2 sats >93%. HOB>45degrees. LS monitored.\n Response:\n O2 sats 93-98% on NC @ 4-6L. LS improved slightly throughout day.\n Continued to desat w/ activity.\n Plan:\n Monitor LS/ o2 sats/ RR. Nebs as needed. Wean o2 as tolerated\n" }, { "category": "Physician ", "chartdate": "2111-10-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 340884, "text": "24 Hour Events:\n -INR: 2.3\n 1.9\n 1.5 s/p 4 un FFP and vit K\n -Tpn continue to rise\n -Cards believe that EKG may be to memory T waves, however, given\n that she has the changes in the distribution of the lateral leads. She\n can be ruled out for MI, however, given her head bleed, she is unable\n to tolerate the treatment- heparin. At this time, obtained lipid panel\n and HbA1c.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 61 (60 - 90) bpm\n BP: 127/59(76) {118/59(62) - 152/96(109)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,251 mL\n 699 mL\n PO:\n TF:\n IVF:\n 728 mL\n 132 mL\n Blood products:\n 523 mL\n 567 mL\n Total out:\n 240 mL\n 150 mL\n Urine:\n 240 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,011 mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 215 K/uL\n 9.9 g/dL\n 154 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 109 mEq/L\n 145 mEq/L\n 28.1 %\n 7.4 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n WBC\n 6.9\n 7.4\n Hct\n 29.2\n 28.1\n Plt\n 212\n 215\n Cr\n 0.9\n 0.8\n TropT\n 0.08\n 0.09\n Glucose\n 135\n 154\n Other labs: PT / PTT / INR:17.0/27.9/1.5, CK / CKMB /\n Troponin-T:87/4/0.09, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.0 mg/dL\n Ck CKMB Tp\n 4am 87 0.09\n 9:30pm 72 4 0.08\n 2:30pm 40 <0.01\n Assessment and Plan\n 87 y/o woman with hypertension, prior admitted with right hand\n numbness in setting of subdural hemorrhage.\n 87 yr old with sx of hand numbness and ? expressive aphasia, resolved.\n Likely . Confounded SDH on CT of unknown onset.\n #. Subdural hemorrhage: Small area of acute hemorrhage in\n chronic-appearing subdural per imaging. No residual deficits per exam\n on arrival to MICU.\n - Hold all anticoagulation\n - INR goal 1 (1.4 per neuron), check q4h. On 5^th unit FFP.\n - vitamin K 10 mg PO X 1 to reverse INR\n - Q2h neuro checks\n - Appreciate Neurosurgery and Neurology input\n - dilantin load tonight (1000 mg) then 100 mg TID per NSG recs\n - HOB elevated\n - repeat head CT this am\n - SSI for euglycemia\n # Chest pain: Patient did have one episode of chest pain in the ED,\n though now is pain-free. EKG does have symmetric T wave inversions,\n though difficult to assess given lack of baseline EKG and fact that\n prior EKG was paced. T wave inversions could reflect intracranial\n pathology though certainly ischemia should be ruled out.\n - monitor closely\n - cycle cardiac enzymes\n - serial EKGs\n - ECHO in the AM to assess wall motion\n - obtain old EKG from ED or PCP in AM\n - No ASA due to SDH\n - No BB currently due to relative hypotension\n # ? : Neurology consultant believes symptoms compatible with lacunar\n infarct, will be difficult to see on CT. Cannot get MRI due to\n pacemaker. UA negative for infection though certainly infection could\n cause re-presentation of neuro deficits.\n - risk stratification with A1c, lipids in AM\n - hold any anticoagulation as per above\n - consider CTA after acute bleed addressed (per Neurology)\n - no sign of infection but will send blood cx with AM labs\n #. Hypertension: Hypertensive on arrival, now with BPs 120s while\n resting comfortably.\n - Hold all antihypertensives\n - consider BB (due to ? ischemia) if SBP > 185\n #. Anemia: Baseline Hct unknown. Add on iron studies\n # GERD: Continue ppi.\n # Osteoporosis: Hold fosamax for now, will resume when clinically\n stable.\n #. FEN - NPO for now, replete lytes prn\n #. PPx - pneumoboots, PPI (home regimen), bowel meds prn\n # Access: 2 PIVs\n #. Code - Full, confirmed with patient, though she would not like to be\n on life support if there is no chance of recovery.\n # Communication: With patient and family. HCP is daughter per\n patient.\n #. Dispo - MICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2111-10-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341007, "text": "Per prior nursing note:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reported that the pain\n has come on at rest and not with exertion per se.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n No deficit noted from neuro checks. Denies headache. Hand grasps equal.\n Smile- no drooping seen. Moving all extremities. Alert and ox3. Follows\n commands.\n Action:\n Neuro checks done q2hrs. Head CT done. Followed by Neuro-.\n Response:\n No deficits observed. No change seen on head CT.\n Plan:\n Neuro checks q2hrs.\n Chest pain\n Assessment:\n Denied CP. AV paced w/ rare PVC\ns. INR 1.5.\n Action:\n Cardiac ECHO done. Daily EKG\ns done. Cardiology following. 1unit of\n FFP given for INR.\n Response:\n ECHO results pending. Continued to deny CP. Repeat INR 1.4.\n Plan:\n Assess CP. Monitor labs. Check ECHO results.\n" }, { "category": "Nursing", "chartdate": "2111-10-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341011, "text": "Per prior nursing note:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reported that the pain\n has come on at rest and not with exertion per se.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n No deficit noted from neuro checks. Denies headache. Hand grasps equal.\n Smile- no drooping seen. Moving all extremities. Alert and ox3. Follows\n commands.\n Action:\n Neuro checks done q2hrs. Head CT done. Followed by Neuro-.\n Response:\n No deficits observed. No change seen on head CT.\n Plan:\n Neuro checks q2hrs.\n Chest pain\n Assessment:\n Denied CP. AV paced w/ rare PVC\ns. INR 1.5.\n Action:\n Cardiac ECHO done. Daily EKG\ns done. Cardiology following. 1unit of\n FFP given for INR.\n Response:\n ECHO results pending. Continued to deny CP. Repeat INR 1.4.\n Plan:\n Assess CP. Monitor labs. Check ECHO results.\n Dyspnea (Shortness of breath)\n Assessment:\n Originally on 02 via NC @ 2L. During ECHO, laid on L side and o2 sats\n decreased to high 80\ns. Subsequently, desated to 88% w/ turns or\n activity. LS clear anteriorly, diminished bases w/ crackles\n way up.\n Action:\n O2 increased to face tent @ 70%. Albuterol neb treatment given.\n HOB>45degrees. LS monitored.\n Response:\n O2 sats 93-98% on face mask @ 70%. LS improved slightly throughout day.\n Continued to desat w/ activity.\n Plan:\n Monitor LS/ o2 sats/ RR. Nebs as needed. Wean o2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2111-10-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341000, "text": "CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2111-10-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341214, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Neurosurgery: Burr hole when cleared by cards, as high-risk per cards\n will consider in AM\n Cardiology: Patient high-risk given evidence of active ischemia.\n Management restricted bleeding risk\n Episode of desaturation overnight\n received 40 mg IV lasix with 600 cc\n output\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 84 (61 - 94) bpm\n BP: 155/80(98) {102/58(74) - 155/88(103)} mmHg\n RR: 28 (11 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,250 mL\n 154 mL\n PO:\n 100 mL\n TF:\n IVF:\n 303 mL\n 154 mL\n Blood products:\n 847 mL\n Total out:\n 900 mL\n 75 mL\n Urine:\n 900 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 350 mL\n 79 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: Alert and oriented to person, place, and time; pleasant, NAD\n HEENT: NCAT, PERRL, EOMI, MMM and I\n CV: RRR, soft systolic murmur loudest at LUSB\n heard along RSB as\n well\n Lungs: diffuse crackles L>R\n Abd: soft, NT/ND, +BS\n Ext: no CCE\n Neuro: CN 2-12 grossly intact; motor\n RUE, otherwise ;\n sensation intact\n Labs / Radiology\n 255 K/uL\n 11.6 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 109 mEq/L\n 143 mEq/L\n 33.5 %\n 13.7 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n 10:45 AM\n 04:12 AM\n WBC\n 6.9\n 7.4\n 13.7\n Hct\n 29.2\n 28.1\n 31.2\n 33.5\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TropT\n 0.08\n 0.09\n Glucose\n 135\n 154\n 144\n Other labs: PT / PTT / INR:16.1/26.6/1.4, CK / CKMB /\n Troponin-T:175/4/0.09, ALT / AST:106/162, Alk Phos / T Bili:106/0.6,\n Differential-Neuts:85.9 %, Lymph:10.3 %, Mono:2.8 %, Eos:0.8 %,\n Albumin:3.7 g/dL, LDH:329 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Fluid analysis / Other labs: iron studies pending, stim test WNL,\n dilantin 11.5\n Imaging:\n No significant change in chronic left subdural hematoma. No\n evidence for new hemorrhage or worsening of associated mass effect.\n Echo: extensive regional LV systolic dysfunction c/w multivessel CAD.\n Mild-mod mitral regurg. Moderate PA systolic HTN. Mild-mod AR.\n Assessment and Plan\n 87 y/o woman with subdural hematoma and possible TIA vs partial\n seizures as well as what appears to be an acute MI with substantial\n heart failure. TIA symptoms have resolved but SDH persists. She also\n has substantial hypoxemia in the setting of multiple units of FFP and\n newly diagnosed systolic CHF. Current problems include:\n # SUBDURAL HEMORRHAGE (SDH)\n Stable. INR goal 1. Currently 1.4. Very\n high risk surgical candidate per cards\n prefer medical management.\n - Vitamin K 10mg PO today\n - avoid warfarin until cleared by neurosurg\n - follow INR. At this point (given pulmonary edema), risks of\n FFP outweigh benefits barring further changes in SDH or increases in\n INR\n - surgical management per neurosurgery\n - change neuro checks to q4hours\n - convert dilantin to PO for sz ppx/control\n - f/u neurosurg, neurology recs\n # MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n - management limited by SDH\n - beta blockade. Will tolerate SBPs down to 110 for now\n - diurese gently today to try to decrease myocardial O2 demand\n and improve pulmonary edema (-500 goal)\n # TIA vs Seizure\n Aside from RUE weakness, sx largely resolved.\n - f/u neurosurgery, neurology recs\n - continue dilantin\n - consider CTA as per neuro for further characterization of ?\n ischemia in setting of inability to do MR b/c pacer\n # HEART FAILURE (CHF), SYSTOLIC, ACUTE\n - diuresis as above\n - beta blockade given risk of VT in peri-infarct period\n - hold on ACEI for now given that above takes priority and BP\n is limited\n - f/u outpatient cardiology records (esp echo to determine if\n any acute ischemic changes manifesting as new pulmonary edema)\n # Anemia\n - follow up iron studies\n # GERD\n - PPI\n # Osteoarthritis\n stable\n ICU Care\n Nutrition: Heart Healthy diet\n Glycemic Control: insulin sliding scale\n Lines:\n 20 Gauge - 10:00 PM\n 22 Gauge - 10:00 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: protonix\n VAP:\n Comments:\n Communication: Comments: daughter and grand-daughter\n status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2111-10-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 340878, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 61 (60 - 90) bpm\n BP: 127/59(76) {118/59(62) - 152/96(109)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,251 mL\n 699 mL\n PO:\n TF:\n IVF:\n 728 mL\n 132 mL\n Blood products:\n 523 mL\n 567 mL\n Total out:\n 240 mL\n 150 mL\n Urine:\n 240 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,011 mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 215 K/uL\n 9.9 g/dL\n 154 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 109 mEq/L\n 145 mEq/L\n 28.1 %\n 7.4 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n WBC\n 6.9\n 7.4\n Hct\n 29.2\n 28.1\n Plt\n 212\n 215\n Cr\n 0.9\n 0.8\n TropT\n 0.08\n 0.09\n Glucose\n 135\n 154\n Other labs: PT / PTT / INR:17.0/27.9/1.5, CK / CKMB /\n Troponin-T:87/4/0.09, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2111-10-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 341189, "text": "Chief Complaint: SDH, acute MI\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 Cards and nsurg consults.\n Troponin increased.\n Episode of hypoxemia.\n History obtained from Medical records, ICU team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Furosemide (Lasix) - 06:10 AM\n Other medications:\n PPI, SQI, metoprolol, statin, nebs\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.5\n HR: 88 (68 - 102) bpm\n BP: 132/75(89) {116/69(82) - 155/88(103)} mmHg\n RR: 26 (18 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Height: 62 Inch\n Total In:\n 1,260 mL\n 335 mL\n PO:\n 100 mL\n 120 mL\n TF:\n IVF:\n 313 mL\n 215 mL\n Blood products:\n 847 mL\n Total out:\n 900 mL\n 1,115 mL\n Urine:\n 900 mL\n 1,115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 360 mL\n -780 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///21/\n Physical Examination\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: Crackles : )\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 11.6 g/dL\n 255 K/uL\n 144 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 109 mEq/L\n 143 mEq/L\n 33.5 %\n 13.7 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n 10:45 AM\n 04:12 AM\n WBC\n 6.9\n 7.4\n 13.7\n Hct\n 29.2\n 28.1\n 31.2\n 33.5\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TropT\n 0.08\n 0.09\n 0.15\n Glucose\n 135\n 154\n 144\n Other labs: PT / PTT / INR:16.1/26.6/1.4, CK / CKMB /\n Troponin-T:175/7/0.15, ALT / AST:106/162, Alk Phos / T Bili:106/0.6,\n Differential-Neuts:85.9 %, Lymph:10.3 %, Mono:2.8 %, Eos:0.8 %,\n Albumin:3.7 g/dL, LDH:329 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n 87 y/o woman with subdural hematoma and possible TIA as well as what\n appears to be an acute MI with substantial heart failure.. TIA\n symptoms have resolved but SDH persists. She also has substantial\n hypoxemia in the setting of multiple units of FFP and newly diagnosed\n systolic CHF. Current problems include:\n SUBDURAL HEMORRHAGE (SDH)\n - continue vitamin K\n - avoid warfarin until cleared by neurosurg\n - follow INR. At this point (given pulmonary edema), risks of\n FFP outweigh benefits barring further changes in SDH or increases in\n INR\n - surgical management per neurosurgery\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n - management limited by SDH\n - beta blockade. Will tolerate SBPs down to 110 for now\n - diurese gently today to try to decrease myocardial O2 demand\n and improve pulmonary edema\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n - diuresis as above\n - beta blockade given risk of VT in peri-infarct period\n - hold on ACEI for now given that above takes priority and BP\n is limited\n Anemia\n - follow\n ICU Care\n Nutrition: PO diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:00 PM\n 22 Gauge - 10:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Maintain in ICU for now given ongoing cardiac, neurologic\n and respiratory issues.\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2111-10-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341339, "text": "Chief Complaint:\n 24 Hour Events:\n -low urine output overnight\n -neurology and neurosurgery ok with ASA 81 - started\n -neuro thinks TIA vs seizure with TIA much more likely --- prev notes\n say consider MRA when stable\n -cards discussed with patient the need for max medical management\n before even considering the longterm possibility of burr hole placement\n -negative 900ccs in past 24 hours\n -took nasal cannula off and desat to mid-80s\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 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 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 81 (75 - 102) bpm\n BP: 153/85(102) {106/36(75) - 153/89(105)} mmHg\n RR: 25 (20 - 29) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Height: 62 Inch\n Total In:\n 859 mL\n 140 mL\n PO:\n 360 mL\n 60 mL\n TF:\n IVF:\n 499 mL\n 80 mL\n Blood products:\n Total out:\n 1,710 mL\n 130 mL\n Urine:\n 1,710 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n -851 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 196 K/uL\n 10.6 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.8 %\n 11.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:55 AM\n 10:45 AM\n 04:12 AM\n 04:45 PM\n 02:50 AM\n WBC\n 6.9\n 7.4\n 13.7\n 11.5\n Hct\n 29.2\n 28.1\n 31.2\n 33.5\n 29.8\n Plt\n 96\n Cr\n 0.9\n 0.8\n 0.9\n 0.9\n 0.7\n TropT\n 0.08\n 0.09\n 0.15\n 0.10\n 0.10\n Glucose\n 135\n 154\n 144\n 151\n 114\n Other labs: PT / PTT / INR:16.1/26.6/1.4, CK / CKMB /\n Troponin-T:109/5/0.10, ALT / AST:106/162, Alk Phos / T Bili:106/0.6,\n Differential-Neuts:85.9 %, Lymph:10.3 %, Mono:2.8 %, Eos:0.8 %,\n Albumin:3.7 g/dL, LDH:329 IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:1.2\n mg/dL\n Assessment and Plan\n 87 y/o woman with subdural hematoma and possible TIA vs partial\n seizures as well as what appears to be an acute MI with substantial\n heart failure. TIA symptoms have resolved but SDH persists. She also\n has substantial hypoxemia in the setting of multiple units of FFP and\n newly diagnosed systolic CHF. Current problems include:\n # SUBDURAL HEMORRHAGE (SDH)\n Stable. INR goal 1. Currently 1.4. Very\n high risk surgical candidate per cards\n prefer medical management.\n - Vitamin K 10mg PO today\n - avoid warfarin until cleared by neurosurg\n - follow INR. At this point (given pulmonary edema), risks of\n FFP outweigh benefits barring further changes in SDH or increases in\n INR\n - surgical management per neurosurgery\n - change neuro checks to q4hours\n - convert dilantin to PO for sz ppx/control\n - f/u neurosurg, neurology recs\n # MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n - management limited by SDH\n - beta blockade. Will tolerate SBPs down to 110 for now\n - diurese gently today to try to decrease myocardial O2 demand\n and improve pulmonary edema (-500 goal)\n # TIA vs Seizure\n Aside from RUE weakness, sx largely resolved.\n - f/u neurosurgery, neurology recs\n - continue dilantin\n - consider CTA as per neuro for further characterization of ?\n ischemia in setting of inability to do MR b/c pacer\n # HEART FAILURE (CHF), SYSTOLIC, ACUTE\n - diuresis as above\n - beta blockade given risk of VT in peri-infarct period\n - hold on ACEI for now given that above takes priority and BP\n is limited\n - f/u outpatient cardiology records (esp echo to determine if\n any acute ischemic changes manifesting as new pulmonary edema)\n # Anemia\n - follow up iron studies\n # GERD\n - PPI\n # Osteoarthritis\n stable\n" }, { "category": "Nursing", "chartdate": "2111-10-12 00:00:00.000", "description": "Generic Note", "row_id": 340868, "text": "TITLE:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP (infusing\n when brought up to floor). She was ordered for hydralazine to be given\n as needed for SBP > 180 but this was not given. At about 1430, she\n complained of chest pressure which did not radiate. This lasted\n about 2 minutes. EKG was obtained, and she was given nitroglycerin and\n the pain resolved. 1st set of cardiac enzymes was negative.\n On arrival to the MICU, the patient is without complaint. She denies\n any numbness of the right arm or hand. She denies any chest pain,\n difficulty breathing, or nausea. She denies any current difficulty with\n speech or headache though does endorse frontal bilateral headache for\n the past 5 days, intermittent in nature, which is not typical for her.\n Denies any head trauma or headache.\n She is not particularly active at baseline; she walks at her house and\n then around in the backyard. She is able to do this without any\n shortness of breath or chest pain. She has had several episodes of\n chest pain in the past few weeks, similar in character, lasting minutes\n which resolve without intervention. She does not report any dyspnea,\n diaphoresis, or nausea with these episodes. She reported that the pain\n has come on at rest and not with exertion per se.\n Plan:\n #. Subdural hemorrhage: Small area of acute hemorrhage in\n chronic-appearing subdural per imaging. No residual deficits\n - Hold all anticoagulation\n - INR goal 1, check q4h, use FFP prn\n - vitamin K 10 mg PO X 1 to reverse INR\n - Q2h neuro checks\n - dilantin load tonight (1000 mg) then 100 mg TID per NSG recs\n - HOB elevated\n - repeat head CT in the morning\n - SSI for euglycemia\n # Chest pain: Patient did have one episode of chest pain in the ED,\n though now is pain-free. EKG does have symmetric T wave inversions,\n though difficult to assess given lack of baseline EKG and fact that\n prior EKG was paced. T wave inversions could reflect intracranial\n pathology though certainly ischemia should be ruled out.\n - monitor closely\n - cycle cardiac enzymes 2^nd set 0.08\n - serial EKGs\n - ECHO in the AM to assess wall motion\n - No ASA due to SDH\n - No BB currently due to relative hypotension\n # ? : Neurology consultant believes symptoms compatible with lacunar\n infarct, will be difficult to see on CT. Cannot get MRI due to\n pacemaker. UA negative for infection though certainly infection could\n cause re-presentation of neuro deficits.\n - risk stratification with A1c, lipids in AM\n - hold any anticoagulation as per above\n - consider CTA after acute bleed addressed (per Neurology)\n - no sign of infection but will send blood cx with AM labs\n #. Hypertension: Hypertensive on arrival, now with BPs 120s while\n resting comfortably.\n - Hold all antihypertensives\n - consider BB (due to ? ischemia) if SBP > 185\n Electrolyte & fluid disorder, other\n Assessment:\n K+ 3.6, runs freq pvc\n Action:\n Repleted with 40 meq of Po KCl\n Response:\n Rare to none pvc\ns. K+ 3.8 in am labs.\n Plan:\n Cont to monitor K + 7 replete as needed.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Neuro checks q 2 hrs. no deficit noted.\n Action:\n Cont Neuro checks q 2 hours, HOB elevated as tolerated.\n Response:\n No changes noted in neuro status.\n Plan:\n Cont Neuro Checks. Repeat CAT scan in am.\n Chest pain\n Assessment:\n St depression.\n Action:\n EKG done, cardiac enzymes recycled. Troponin 0.08 in the evening.\n Response:\n No c/o chest pain.\n Plan:\n Continue cardiac monitoring.\n Central sleep apnea (CSA)\n Assessment:\n As pt sleeps she has periods of shallow breathing & apnoea , MICU Team\n Aware.\n Action:\n Pt awakened & encouraged to breathe. Discussed with team for Bipap.\n Started on 2 lits of O2 via NC. Will need evaluation for Sleep Apnea.\n Response:\n Pt continues to have sleep apnea. O2 sats maintained mid to high 90\n Plan:\n Cont Monitoring, Will need further evaluation.\n Total 4 FFP\ns given, Inr down to 1.5 . No plans to transfuse at\n present as per MICU team.\n" }, { "category": "Nursing", "chartdate": "2111-10-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341443, "text": "She also has substantial hypoxemia in the setting of multiple units of\n FFP and newly diagnosed systolic CHF.\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2111-10-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341449, "text": "HPI:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP to normalize\n her INR. After FFP completed complained of chest pressure which\n did not radiate. This lasted about 2 minutes. EKG was obtained, and she\n was given nitroglycerin and the pain resolved. 1st set of cardiac\n enzymes was negative. Troponin (0.09) + T wave inversions in all\n precordial leads. Echo showing EF 30%. Pt with increasing 02\n requirements, increasing SOB with CXRay showing fluid overload. She\n was diuresised, had serial Head CTs which have not shown further\n progression of her SDH.\n ROS:\n Pt is currently A&Ox3, and cooperative. Neuro exam\n unremarkable. . OOB to the chair with one assist. O2 weanned\n off currently 02 sats 94-97%. Lungs with fine crackles at bases. RR\n teens even and unlabored. Pt denies SOB. Tele Vpaced 70-80\ns with occ\n PVC\ns . Hemodynamically stable no edema. Tolerating Cardiac diet. Pt\n frequently incont of stool (pt baseline). + BS in 4 quadrents. Foley\n draining large amounts of clear yellow urine. Skin is intact. Phos\n 1.2 this AM currently getting repleted. Pt is Full , Daughter is\n contact & HCP.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro Exam benign. , , A&Ox3, OOB to chair most of\n afternoon.\n Action:\n Started on 325 mg ASA this afternoon\n Response:\n Pts neuro exam has remained unchanged\n Plan:\n Pt to have repeat CT this evening 12 hours after 325 ASA dose\n (midnight), continue with serial neuro exams. To have ?burr hole\n placement as outpatient to drain SDH once pt is medically stable\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Peak tropnin 0.15, pt without CP tele V paced 70-80\ns with rare PVC\n BP increased to 25 TID this AM.\n Action:\n Repeat EKG done.\n Response:\n BP tolerated increase in BB, pt denies C/O CP\n Plan:\n Titrate BB as tolerated. ? starting ACE as BP tolerates monitor\n cardiac status\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Pt remains with fine crackles at bases, 02 sats 94-95 on RA, RR 12-24.\n Action:\n Additional 40 mg IV lasix given\n Response:\n Diuresising well, able to wean 02 off. Pt remains without c/o dypsnea\n Plan:\n Goal negative 500 cc today\n" }, { "category": "Nursing", "chartdate": "2111-10-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341451, "text": "HPI:\n Ms. is an 87 y/o woman with PMH notable for hypertension and prior\n TIA on coumadin who presents following several hours of right hand\n numbness and one episode of aphasia earlier today. Patient notes first\n episodes of right hand numbness last Thursday. Lasted several hours and\n resolved on its own. This morning, woke up with right hand numbness\n which eventually resolved over several hours. Then, when the patient\n went to get iced coffee with her daughter, she could not speak her\n intended words. At that time, her daughter took her to . There, she had a head CT which demonstrated acute on chronic\n SDH with mass effect. she was treated with decadron and then\n transferred to due to patient family preference.\n In our ED, the patient's initial vitals were T 96.7, BP 185/76, HR 68,\n RR 16, 97% on RA. NSG was contact. She was given 1 U FFP to normalize\n her INR. After FFP completed complained of chest pressure which\n did not radiate. This lasted about 2 minutes. EKG was obtained, and she\n was given nitroglycerin and the pain resolved. 1st set of cardiac\n enzymes was negative. Troponin (0.15) + T wave inversions in all\n precordial leads. Echo showing EF 30%. Pt with increasing 02\n requirements, increasing SOB with CXRay showing fluid overload. She\n was diuresised, had serial Head CTs which have not shown further\n progression of her SDH.\n ROS:\n Pt is currently A&Ox3, and cooperative. Neuro exam\n unremarkable. . OOB to the chair with one assist. O2 weanned\n off currently 02 sats 94-97%. Lungs with fine crackles at bases. RR\n teens even and unlabored. Pt denies SOB. Tele Vpaced 70-80\ns with occ\n PVC\ns . Hemodynamically stable no edema. Tolerating Cardiac diet. Pt\n frequently incont of stool (pt baseline). + BS in 4 quadrents. Foley\n draining large amounts of clear yellow urine. Skin is intact. Phos\n 1.2 this AM currently getting repleted. Pt is Full , Daughter is\n contact & HCP.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro Exam benign. , , A&Ox3, OOB to chair most of\n afternoon.\n Action:\n Started on 325 mg ASA this afternoon\n Response:\n Pts neuro exam has remained unchanged\n Plan:\n Pt to have repeat CT this evening 12 hours after 325 ASA dose\n (midnight), continue with serial neuro exams. To have ?burr hole\n placement as outpatient to drain SDH once pt is medically stable\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Peak tropnin 0.15, pt without CP tele V paced 70-80\ns with rare PVC\n BP increased to 25 TID this AM.\n Action:\n Repeat EKG done.\n Response:\n BP tolerated increase in BB, pt denies C/O CP\n Plan:\n Titrate BB as tolerated. ? starting ACE as BP tolerates monitor\n cardiac status\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Pt remains with fine crackles at bases, 02 sats 94-95 on RA, RR 12-24.\n Action:\n Additional 40 mg IV lasix given\n Response:\n Diuresising well, able to wean 02 off. Pt remains without c/o dypsnea\n Plan:\n Goal negative 500 cc today\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 63.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Universal\n PMH: HTN tia W/U one year aggo\n CV-PMH:\n Additional history: Pacemaker insertion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:76\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n None\n O2 saturation:\n 93% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 896 mL\n 24h total out:\n 1,290 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 02:50 AM\n Potassium:\n 3.6 mEq/L\n 02:50 AM\n Chloride:\n 110 mEq/L\n 02:50 AM\n CO2:\n 23 mEq/L\n 02:50 AM\n BUN:\n 22 mg/dL\n 02:50 AM\n Creatinine:\n 0.7 mg/dL\n 02:50 AM\n Glucose:\n 114 mg/dL\n 02:50 AM\n Hematocrit:\n 29.8 %\n 02:50 AM\n Finger Stick Glucose:\n 101\n 12:00 PM\n Valuables / Signature\n Patient valuables: Sent with pt\n valuables:\n Clothes: S\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 685\n Transferred to: 310\n Date & time of Transfer: 1630\n" }, { "category": "Radiology", "chartdate": "2111-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032636, "text": " 11:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? widened mediastinum\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with right hand numbness/tingling, chest pain.\n REASON FOR THIS EXAMINATION:\n ? widened mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right hand numbness and tingling, to evaluate for wide mediastinum.\n\n FINDINGS: No previous images. Cardiac silhouette is enlarged and there is\n tortuosity of the aorta and diffuse prominence of ill-defined interstitial\n markings consistent with elevated pulmonary venous pressure. No acute focal\n infiltrate. Pacemaker device is in place.\n\n No definite abnormality involving the mediastinum, though if this is a serious\n clinical concern, CT would be necessary for further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1033636, "text": " 8:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change in appearance of SDH. Please do in early am(\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with recent acute on chronic SDH.\n REASON FOR THIS EXAMINATION:\n Interval change in appearance of SDH. Please do in early am(before 7am)\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 2:15 PM\n PFI: No significant interval change in the appearance of the left subdural\n hematoma. There is no increase in associated mass effect or _____.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old woman with acute-on-chronic subdural hemorrhage.\n Evaluate for interval change.\n\n COMPARISON: CT head from at 0:15 hours.\n\n TECHNIQUE: Contiguous axial images were obtained through the head without the\n administration of IV contrast.\n\n FINDINGS: Again seen is a low attenuation subdural collection overlying\n the left frontal convexity. There are small hypodense foci in the inferior-\n posterior aspect, which do not appear changed. There is no increase in mass\n effect, associated edema, ventricular compression, or midline shift. There is\n no evidence for new hemorrhage. The grey-white differentiation is\n preserved. There is no evidence of infarction.\n\n The osseous structures remain unremarkable. The visualized paranasal sinuses\n and mastoid air cells are normal.\n\n IMPRESSION: No significant change in the extent or appearance of the left\n subdural hematoma. No increase in mass effect, midline shift, or associated\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1033637, "text": ", P. 8:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change in appearance of SDH. Please do in early am(\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with recent acute on chronic SDH.\n REASON FOR THIS EXAMINATION:\n Interval change in appearance of SDH. Please do in early am(before 7am)\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No significant interval change in the appearance of the left subdural\n hematoma. There is no increase in associated mass effect or _____.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1033327, "text": " 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess subdural: needs scan at approx 2300 \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with subdural hemorrhage and mi now restarted on full dose\n aspirin, needs head ct 12 hours later to assess interval change\n REASON FOR THIS EXAMINATION:\n assess subdural: needs scan at approx 2300 \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:00 AM\n PFI: No change in extent of chronic left subdural hematoma. However, along\n its inferior aspect, hyperdense foci appear slightly larger than on the prior\n study, and could reflect a tiny amount of acute on chronic bleeding. No\n change in mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old woman with subdural hemorrhage, restarted on full\n dose aspirin following MI; assess interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: The low attenuation collection along the left convexity is\n unchanged in extent, measuring 13 mm in its greatest width. However, along\n the inferior aspect of the collection, there are hyperdense foci, some of\n which appear larger than on the prior exam. These could reflect acute on\n chronic bleeding. There has been no interval change in mass effect upon the\n left frontal cortex, with approximately 5 mm of midline shift.\n\n No other foci of hemorrhage are identified. There is no edema or infarction.\n Ventricles and sulci are normal in size and configuration. The basilar\n cisterns are intact. -white differentiation is maintained. There is no\n fracture or abnormality of paranasal sinues or mastoid air cells.\n\n IMPRESSIONS: No change in extent of chronic left subdural hematoma. However,\n foci of increased attenuation along its inferior extent may represent a small\n amount of acute on chronic bleeding. No change in mass effect on the left\n frontal cortex.\n\n\n NOTE ADDED AT ATTENDING REVIEW: The slight apparent increase in density within\n the inferior portion of the left subdural hematoma may be due to changes in\n head position within the scanner, rather than real appearance of new\n hemorrhage.\n (Over)\n\n 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess subdural: needs scan at approx 2300 \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Field of view: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2111-10-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1033328, "text": ", P. 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess subdural: needs scan at approx 2300 \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with subdural hemorrhage and mi now restarted on full dose\n aspirin, needs head ct 12 hours later to assess interval change\n REASON FOR THIS EXAMINATION:\n assess subdural: needs scan at approx 2300 \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change in extent of chronic left subdural hematoma. However, along\n its inferior aspect, hyperdense foci appear slightly larger than on the prior\n study, and could reflect a tiny amount of acute on chronic bleeding. No\n change in mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1032715, "text": " 10:26 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please perform in AM on \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with subdural hemorrhage, acute on chronic, seen on .\n REASON FOR THIS EXAMINATION:\n please perform in AM on \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 2:05 PM\n PFI: No significant change in chronic left subdural hematoma. There is no\n worsening of associated mass effects and no evidence of herniation. There is\n no evidence of active new hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old female with subdural hemorrhage seen on .\n Evaluate for resolution.\n\n COMPARISON: CT of the head from at 14:55.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: The left subdural collection is unchanged from prior examination.\n It measures at most approximately 1.4 cm in thickness. It has low attenuation\n with average Hounsfield units of 16, consistent with primarily chronic\n hematoma. There is no evidence for acute hemorrhage. Linear areas of increased\n density within this collection likely represent fibrovascular membranes and\n are unchanged from prior study. There is stable, minimal effacement of the\n left lateral ventricle, particularly the frontal , and also stable minimal\n rightward shift of normally midline structures. Incidentally noted is a small\n hypodensity adjacent to the frontal of right lateral ventricle, likely\n sequelae of a prior lacunar infarct.\n\n The mastoid and ethmoid air cells and the paranasal sinuses are normal.\n\n IMPRESSION: No significant change in chronic left subdural hematoma. No\n evidence for new hemorrhage or worsening of associated mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1032716, "text": ", D. MED MICU 10:26 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please perform in AM on \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with subdural hemorrhage, acute on chronic, seen on .\n REASON FOR THIS EXAMINATION:\n please perform in AM on \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No significant change in chronic left subdural hematoma. There is no\n worsening of associated mass effects and no evidence of herniation. There is\n no evidence of active new hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032873, "text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrates, pneumonia\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with SDH, ? MI.\n REASON FOR THIS EXAMINATION:\n ? infiltrates, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subdural hematoma, to evaluate for pneumonia.\n\n FINDINGS: In comparison with study of , there is again diffuse prominence\n of pulmonary markings consistent with elevated pulmonary venous pressure.\n There is more coalescent area of opacification in the left perihilar and upper\n lung zone. Although this could represent asymmetric edema, aspiration\n pneumonia should be seriously considered in this clinical setting.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1032582, "text": " 2:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with h/o sdh, on coumadin with HA and R sided tinglings\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SUN 3:22 PM\n L convexity subdural measuring 1.8 cm from the inner table, likely chronic\n with mild mass effect and no midline shift or herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old woman with history of subdural hemorrhage on Coumadin\n with headache and right-sided tingling.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired images were obtained from the skull vertex to the\n foramen magnum without intravenous contrast.\n\n FINDINGS: A left subdural collection extends at most 1.9 cm from the inner\n table, measuring 15 . There is no evidence of parenchymal hemorrhage. There\n is a 4-mm shift of normally midline structures with compression of the left\n frontal of the left lateral ventricle but no evidence of herniation. The\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION: Predominantly chronic left subdural hematoma measuring up to 1.8\n cm from the inner table with mild associated mass effect and midline shift.\n There is no evidence of herniation.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033094, "text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with acute on chronic SDH, AV pacemaker\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 10:27 AM\n Mild pulmonary edema improved. Small bilateral pleural effusions unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:01 A.M., \n\n HISTORY: Acute and chronic SDH. AV pacemaker.\n\n IMPRESSION: AP chest compared to and 9:\n\n Mild pulmonary edema improved substantially. Small bilateral pleural\n effusions unchanged. Heart size normal. Transvenous right atrial and right\n ventricular pacer leads in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033095, "text": ", D. MED MICU 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with acute on chronic SDH, AV pacemaker\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Mild pulmonary edema improved. Small bilateral pleural effusions unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032720, "text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate, pulmonary edema\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with intracranial hemorrhage.\n REASON FOR THIS EXAMINATION:\n ? infiltrate, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage, to evaluate for pneumonia.\n\n FINDINGS: In comparison with study of , there is again some ill-defined\n pulmonary markings consistent with elevated pulmonary venous pressure. These\n are more prominent in the left perihilar region. This could reflect\n asymmetric edema though the possibility of some aspiration in the posterior\n aspect of the upper or lower lobe on the left should be considered.\n\n\n" }, { "category": "Echo", "chartdate": "2111-10-12 00:00:00.000", "description": "Report", "row_id": 87293, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Hypertension. Source of embolism.\nHeight: (in) 62\nWeight (lb): 136\nBSA (m2): 1.62 m2\nBP (mm Hg): 102/80\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:17\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.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV. Normal IVC diameter (<2.1cm) with\n35-50% decrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Apical LV aneurysm.\nModerate regional LV systolic dysfunction. No LV mass/thrombus. TDI E/e' >15,\nsuggesting PCWP>18mmHg.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; mid inferolateral - hypo; mid anterolateral -\nhypo; anterior apex - akinetic; septal apex- akinetic; lateral apex -\nakinetic; 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.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild to moderate\n(+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. There\nis moderate regional left ventricular systolic dysfunction with near akinesis\nof the distal half of the left ventricle. Basal segments contract well (LVEF\n30%). The apex is aneurysmal, but no masses or thrombi are seen( but images\nquality is suboptimal). 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 mildly thickened.\nNo aortic stenosis is seen. Mild to moderate (+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Extensive regional left ventricular systolic dysfunction c/w\nmultivessel CAD. Mild-moderate mitral regurgitation. Moderate pulmonary artery\nsystolic hypertension. Mild-moderate aortic regurgitation.\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": "2111-10-11 00:00:00.000", "description": "Report", "row_id": 223124, "text": "Sinus rhythm with sinus arrhythmia. Left axis deviation. Left ventricular\nhypertrophy. Deep symmetric T wave inversions throughout suggestive of\ncranial process or myocardial ischemia. Compared to the previous tracing\nA-V sequential pacemaking is no longer seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2111-10-11 00:00:00.000", "description": "Report", "row_id": 223125, "text": "A-V sequential pacemaker. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2111-10-14 00:00:00.000", "description": "Report", "row_id": 223121, "text": "Sinus rhythm. Short P-R interval. Left axis deviation. Intraventricular\nconduction delay. ST-T wave abnormalities. Since the previous tracing\nof ventricular pacing is no longer seen. Widespread T wave inversion\npersists.\n\n" }, { "category": "ECG", "chartdate": "2111-10-12 00:00:00.000", "description": "Report", "row_id": 223122, "text": "Sinus rhythm with ventricular pacing. Compared to the previous tracing\nventricular pacing is new.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2111-10-11 00:00:00.000", "description": "Report", "row_id": 223123, "text": "Atrial fibrillation. Left axis deviation. Left ventricular hypertrophy.\nDeep T wave inversions throughout suggestive of cranial process or myocardial\nischemia. Compared to the previous tracing atrial fibrillation is new.\nTRACING #3\n\n" } ]

[ { "category": "Echo", "chartdate": "2125-06-22 00:00:00.000", "description": "Report", "row_id": 60629, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease\nHeight: (in) 70\nWeight (lb): 214\nBSA (m2): 2.15 m2\nBP (mm Hg): 98/64\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 11:48\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 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. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. No 2D or Doppler evidence of distal arch 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. Calcified tips\nof papillary muscles. No MS. Trivial MR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. 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 mildly dilated. 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. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrivial mitral regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-06-22 00:00:00.000", "description": "ANTEGRADE UROGRAPHY", "row_id": 1017355, "text": " 8:49 AM\n PERC NEPHROSTO Clip # \n Reason: Please place left nephrostomy tube\n Admitting Diagnosis: OBSTRUCTED RENAL STONE\n Contrast: OPTIRAY Amt: 35\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n * ANTEGRADE UROGRAPHY MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with L obstructing calculi and pyelonephritis\n REASON FOR THIS EXAMINATION:\n Please place left nephrostomy tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old man with left obstructing calculi and pyelonephritis.\n Request for percutaneous left sided nephrostomy.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\n attending radiologist, who was an active participant during the procedure.\n\n PROCEDURE AND FINDINGS: Informed consent was obtained from the patient after\n the risks and benefits of the procedure were explained. Preprocedural timeout\n was performed documenting patient identity. Patient was placed prone on the\n fluoroscopic table and the left flank was prepped and draped in the normal\n sterile fashion. Using ultrasound guidance, a 21 Gauge Chiba type needle was\n used to puncture the left renal pelvis. A 0.018 wire was advanced through the\n needle into the renal pelvis under fluoroscopic guidance. The needle was\n removed and the inner portion of an Accustick sheath was advanced over the\n wire under fluoroscopic guidance into the renal pelvis and the inner dilator\n and the wire were removed. Small amount of contrast material was injected\n through the Accustick sheath. The nephrostogram demonstrated a markedly\n dilated collecting system.\n Another 21 Gauge needle was used to get access into a posterior superior\n calix, under fluoroscopic guidance. A 0.018 guidewire was advanced through the\n needle into the renal pelvis. The needle was removed and exchanged for an\n Accustick sheath. The inner dilator and the wire were removed. A small amount\n of contrast material was injected and confirmed good position in the renal\n pelvis, through posterior calix with immediate return of slightly cloudy\n appearing urine. At this time, a sample of urine was removed and sent for\n analysis and culture. A 0.035 Amplatz guidewire was advanced through the\n caliceal access, and coiled into the renal pelvis. The Accustick sheath was\n removed and the tract was dilated with 7 and 8 French dilators, and an 8\n French nephrostomy catheter was advanced over the guide wire into the renal\n pelvis. Under fluoroscopic observation, the nephrostomy catheter was coiled in\n the renal pelvis, and the pigtail was locked and secured.\n\n The patient tolerated the procedure well with no immediate complications. The\n catheter was secured using an 0 silk sutures and a Stat lock device.\n\n Conscious sedation was provided during the procedure for patient comfort in\n addition to 1% lidocaine used for topical anesthetic. 75 mcg of Fentanyl and\n (Over)\n\n 8:49 AM\n PERC NEPHROSTO Clip # \n Reason: Please place left nephrostomy tube\n Admitting Diagnosis: OBSTRUCTED RENAL STONE\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1.5 mg of Versed were given throughout the total intraservice time of 20\n minutes in divided doses during which the patient's hemodynamic parameters\n were continuously monitored.\n\n IMPRESSION:\n 1. Successful placement of 8 French left-sided percutaneous nephrostomy. The\n catheter is attached to a bag for external drainage.\n\n 2. Demonstration of known marked left-sided hydronephrosis and marked\n hydroureter.\n\n\n Urine samples obtaind nduring the procedure were sent for microbiological\n evaluation. Please follow- up on these results. Thank you.\n\n\n" }, { "category": "ECG", "chartdate": "2125-06-22 00:00:00.000", "description": "Report", "row_id": 109885, "text": "Artifact is present. Sinus tachycardia. Non-specific ST-T wave changes.\nCompared to the previous tracing the rate is faster.\n\n" }, { "category": "Nursing", "chartdate": "2125-06-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 632974, "text": "69 y/o M with a PMH significant for bilateral renal stones s/p\n extracorpeal shockwave lithotripsy in and self catheterizes\n at home, HTN & hyperlipidemia who presents from OSH with L ureteral\n obstructing stone. Renal U/S done on identified no\n hydronephrosis, 7mm RLP stone, 5mm LLP stone. On he developed L\n flank pain radiating to groin and one episode nausea, vomiting. The\n pain resolved spontaneously that evening, however it returned on .\n Associated with this he developed a fever, chills and general malaise.\n He presented to Hospital with fever and left renal colic on\n . CT scan identified two stones obstructing the L ureter together\n with moderate hydroureteronephrosis. He was transferred to for\n further management.\n .H/O nephrolithiasis (Kidney Stones)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2125-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 632975, "text": "Chief Complaint: Pyelonephritis\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:03 AM\n CALLED OUT\n Pt underwent Left nephrostomy tube placement with interventional\n radiology emergently. Cultures sent. Pt afebrile overnight. On\n cefepime.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 09:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Midazolam (Versed) - 09:30 AM\n Heparin Sodium (Prophylaxis) - 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 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 85 (78 - 96) bpm\n BP: 141/80(94) {89/46(62) - 141/85(96)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,359 mL\n 405 mL\n PO:\n 300 mL\n 240 mL\n TF:\n IVF:\n 2,059 mL\n 165 mL\n Blood products:\n Total out:\n 3,215 mL\n 1,675 mL\n Urine:\n 2,415 mL\n 1,675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,144 mL\n -1,270 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 11.8 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 140 mEq/L\n 35.4 %\n 16.3 K/uL\n [image002.jpg]\n 05:39 AM\n 06:19 AM\n 05:28 AM\n WBC\n 2.6\n 16.3\n Hct\n 36.0\n 35.4\n Plt\n 131\n 137\n Cr\n 0.8\n 0.6\n TropT\n 0.04\n TCO2\n 22\n Glucose\n 108\n 117\n Other labs: PT / PTT / INR:13.8/29.1/1.2, CK / CKMB /\n Troponin-T:1233/15/0.04, Lactic Acid:3.5 mmol/L, Albumin:3.6 g/dL,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Imaging: TTE - The left atrium is mildly dilated. Left ventricular\n wall thickness, cavity size and regional/global systolic function are\n normal (LVEF 60-70%) There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion\n .\n CXR IMPRESSION:\n 1. Improvement of mild pulmonary edema.\n 2. Small left pleural effusion.\n 3. No aspiration.\n Microbiology: 10:00 am URINE NEPHROSTAMY TUBE PLACEMENT.\n URINE CULTURE (Pending):\n Assessment and Plan\n Mr. is a 69 year old male with history of hypertension,\n hyperlipidemia, renal stones who presents from OSH with left\n obstructing renal stone and acute complicated pyelonephritis.\n .\n #Sepsis: Secondary to complicated pyelonephritis; spiked temp to 102.4\n this AM. + Rigors, altered mental status, tachycardia. BP stable.\n Elevated to lactate. 8% bands on WBC counts. Given potential urinary\n tract organisms, will add vanco to cover enterococcus and continue\n zosyn.\n - Continue zosyn for empiric coverage\n - Add vanco for Gram + coverage\n - monitor wbc count\n - f/u cultures\n - demerol for rigors\n - IVFs prn for hypotension\n - Goal MAP greater than 65\n # Pyelonephritis: Obstructing left renal stone in setting of acute\n complicated pyelonephritis. Per recent renal note, stones attributed\n to mild primary hyperparathyroidism vs secondary hyperparathyroidism.\n He had hypercalciuria on 24hr urine sample. Seen by urology in the ED.\n - Plan for left nephrostomy tube placement this morningwith\n interventional radiology.\n - Continue broad spectrum antibiotics for complicated pyelonephritis\n given setting of obstruction as well as self catheterization.\n - Follow blood and urine cultures\n - NPO for procedure\n - Foley in place\n - Pain management as needed\n morphine written PRN\n - 2 PIV in place. Consider CVL placement if hypotension, tachycardia.\n # Lactic acidosis: secondary to sepsis\n # Pulmonary edema: Likely secondary to acute diastolic dysfunction in\n setting of hypertensive urgency\n - Check ECHO\n - Monitor I/O: goal -500cc if BP tolerates\n .\n # Urinary retention: Self catheterizes at home.\n - Foley in place\n # Hypertension: Transiently hypertensive in setting of fevers and\n rigors. BP now normal\n - continue to hold bblocker in setting of sepsis\n # Hyperlipidemia\n - Continue statin as per home regimen\n .\n # Gout:\n - Continue allopurinol\n .\n # Hypothyroidism\n - Continue synthroid\n - Recheck TSH\n .\n #FEN\n - NPO for procedure\n - replete lytes PRN\n .\n #ACCESS: PIV x2.\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - bowel meds\n .\n #CODE: FULL\n #COMMUNICATION: patient\n .\n #DISPO: ICU until procedure\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2125-06-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 632976, "text": "69 y/o M with a PMH significant for bilateral renal stones s/p\n extracorpeal shockwave lithotripsy in and self catheterizes\n at home, HTN & hyperlipidemia who presents from OSH with L ureteral\n obstructing stone. Renal U/S done on identified no\n hydronephrosis, 7mm RLP stone, 5mm LLP stone. On he developed L\n flank pain radiating to groin and one episode nausea, vomiting. The\n pain resolved spontaneously that evening, however it returned on .\n Associated with this he developed a fever, chills and general malaise.\n He presented to Hospital with fever and left renal colic on\n . CT scan identified two stones obstructing the L ureter together\n with moderate hydroureteronephrosis. He was transferred to for\n further management.\n .H/O nephrolithiasis (Kidney Stones)\n Assessment:\n s/p left nephrosotomy tube placement on for hydronephrosis.\n Nephrostomy tube with 575ccs slightly pink output. Pt denies any pain\n and is afebrile. Hemodynamics stable. Foley cath in place with\n adequate hourly uo.\n Action:\n Nephrosotomy output followed closely as well as pt\ns pain level.\n Followed fever curve and administered antibiotics as ordered. Awating\n final results of cultures sent last noc.\n Response:\n Stable ovenoc and remains afebrile. Pt is pain free.\n Plan:\n Transfer to medical floor bed when available. Follow fluid balance\n closely. Follow recommendations of urology. Continue to assess pt\n pain level and medicate with ivp morphine as needed\n Pt is a&o x3. pleasant and cooperative. Has not required any o2 with rr\n high teens to low 20\ns and o2 sats> 93%. Lungs cta. Tolerating reg diet\n without c/o n/v . abd benign on exam. Has 2 piv\ns in place . pt\ns wife\n was called and is aware of pt\ns transfer to floor bed\n Demographics\n Attending MD:\n \n Admit diagnosis:\n OBSTRUCTED RENAL STONE\n Code status:\n Full code\n Height:\n Admission weight:\n 104.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Smoker\n CV-PMH:\n Additional history: 69M with history of bilateral renal stones s/p ESWL\n (extracorpeal\n shockwave lithotripsy) and with Dr. . Renal U/S\n identified no hydronephrosis, 7mm RLP stone, 5mm LLP stone.\n He suffered left renal colic and fever 101.9 at Hospital .\n today. CT scan identified two left UVJ stones measuring 9.4x4.2mm\n together with moderate hydroureteronephrosis. He was transferred\n to for further management. Here his SBP nadir to 80/54,\n normally in 120-130s. He was tx'd with 4liters of NS with stabilazation\n of his bp. He is transferred to MICU for further management.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:150\n D:87\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 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 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 790 mL\n 24h total out:\n 2,490 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 05:28 AM\n Potassium:\n 3.6 mEq/L\n 05:28 AM\n Chloride:\n 110 mEq/L\n 05:28 AM\n CO2:\n 22 mEq/L\n 05:28 AM\n BUN:\n 14 mg/dL\n 05:28 AM\n Creatinine:\n 0.6 mg/dL\n 05:28 AM\n Glucose:\n 117 mg/dL\n 05:28 AM\n Hematocrit:\n 35.4 %\n 05:28 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 409\n Transferred to: 1162 \n Date & time of Transfer: o6/14/08 1100\n" }, { "category": "Physician ", "chartdate": "2125-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 632977, "text": "Chief Complaint: Hydronephrosis\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 69 yo man presented with urosepsis, found to have obstructing stone on\n left, s/p nephrostomy tube.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:03 AM\n CALLED OUT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 09:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n ASA\n MVI\n Levoxyl\n simvastatin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 98 (78 - 98) bpm\n BP: 165/61(91) {91/49(62) - 165/87(139)} mmHg\n RR: 28 (15 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,359 mL\n 799 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 2,059 mL\n 199 mL\n Blood products:\n Total out:\n 3,215 mL\n 2,690 mL\n Urine:\n 2,415 mL\n 2,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,144 mL\n -1,891 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\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: Crackles : bases)\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.8 g/dL\n 137 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 140 mEq/L\n 35.4 %\n 16.3 K/uL\n [image002.jpg]\n 05:39 AM\n 06:19 AM\n 05:28 AM\n WBC\n 2.6\n 16.3\n Hct\n 36.0\n 35.4\n Plt\n 131\n 137\n Cr\n 0.8\n 0.6\n TropT\n 0.04\n TCO2\n 22\n Glucose\n 108\n 117\n Other labs: PT / PTT / INR:13.8/29.1/1.2, CK / CKMB /\n Troponin-T:1233/15/0.04, Lactic Acid:3.5 mmol/L, Albumin:3.6 g/dL,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Imaging: Echo: EF 60-70%, no valvular disease.\n CXR: Improvement of mild pulmonary edema\n Microbiology: Urine culture pending.\n Urine culture from OSH with GNRs, no speciation yet.\n Assessment and Plan\n Urosepsis: improved on cefepime, follow-up OSH urine culture\n Obstructing Stone: s/p nephrostomy, f/u care as per urology\n HTN: Can restart lopressor\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:54 AM\n 20 Gauge - 04:55 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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 632978, "text": "Chief Complaint: Pyelonephritis\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:03 AM\n CALLED OUT\n Pt underwent Left nephrostomy tube placement with interventional\n radiology emergently. Cultures sent. Pt afebrile overnight. On\n cefepime.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 09:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 09:30 AM\n Midazolam (Versed) - 09:30 AM\n Heparin Sodium (Prophylaxis) - 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 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 85 (78 - 96) bpm\n BP: 141/80(94) {89/46(62) - 141/85(96)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,359 mL\n 405 mL\n PO:\n 300 mL\n 240 mL\n TF:\n IVF:\n 2,059 mL\n 165 mL\n Blood products:\n Total out:\n 3,215 mL\n 1,675 mL\n Urine:\n 2,415 mL\n 1,675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,144 mL\n -1,270 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 11.8 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 140 mEq/L\n 35.4 %\n 16.3 K/uL\n [image002.jpg]\n 05:39 AM\n 06:19 AM\n 05:28 AM\n WBC\n 2.6\n 16.3\n Hct\n 36.0\n 35.4\n Plt\n 131\n 137\n Cr\n 0.8\n 0.6\n TropT\n 0.04\n TCO2\n 22\n Glucose\n 108\n 117\n Other labs: PT / PTT / INR:13.8/29.1/1.2, CK / CKMB /\n Troponin-T:1233/15/0.04, Lactic Acid:3.5 mmol/L, Albumin:3.6 g/dL,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Imaging: TTE - The left atrium is mildly dilated. Left ventricular\n wall thickness, cavity size and regional/global systolic function are\n normal (LVEF 60-70%) There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion\n .\n CXR IMPRESSION:\n 1. Improvement of mild pulmonary edema.\n 2. Small left pleural effusion.\n 3. No aspiration.\n Microbiology: 10:00 am URINE NEPHROSTAMY TUBE PLACEMENT.\n URINE CULTURE (Pending):\n Assessment and Plan\n Mr. is a 69 year old male with history of hypertension,\n hyperlipidemia, renal stones who presents from OSH with left\n obstructing renal stone and acute complicated pyelonephritis.\n #Sepsis: Urosepsis. 2 different e coli, 1 is pansensitive, other not\n speciated. blood cultures w/ this unspeciated GNR. Cultures at\n hospital . + urine / blood on , pending here.\n -continue cefepime, until final then can narrow\n -hemodynamically stable\n -afebrile\n -s/p nephrostomy tube \n # Pyelonephritis: Obstructing left renal stone in setting of acute\n complicated pyelonephritis. Per recent renal note, stones attributed\n to mild primary hyperparathyroidism vs secondary hyperparathyroidism.\n He had hypercalciuria on 24hr urine sample. Seen by urology in the ED.\n -f/u w/ nephrology on w/ ,appt made\n -f/u w/ urology in weeks- per urology note, needs to be post\n infection for 2-3 weeks prior to intervention upon stone, for bladder\n thickening also will need repeat outpatient cystoscopy per old notes\n # Lactic acidosis: secondary to sepsis\n # Pulmonary edema:\n -ECHO normal, likely due to fluid resuscitation, sating well on room\n air, improving, autodiuresing.\n # Urinary retention: Self catheterizes at home.\n - Foley in place\n # Hypertension: restart home meds if becomes hypertensive, now\n normotensive\n # Hyperlipidemia\n - Continue statin as per home regimen\n # Gout:\n - Continue allopurinol\n # Hypothyroidism\n - Continue synthroid\n - Recheck TSH\n #FEN\n -regular diet\n - replete lytes PRN\n #ACCESS: PIV x2.\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - bowel meds\n #CODE: FULL\n #COMMUNICATION: patient\n #DISPO: tx to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2125-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 632979, "text": "69 y/o M with a PMH significant for bilateral renal stones s/p\n extracorpeal shockwave lithotripsy in and self catheterizes\n at home, HTN & hyperlipidemia who presents from OSH with L ureteral\n obstructing stone. Renal U/S done on identified no\n hydronephrosis, 7mm RLP stone, 5mm LLP stone. On he developed L\n flank pain radiating to groin and one episode nausea, vomiting. The\n pain resolved spontaneously that evening, however it returned on .\n Associated with this he developed a fever, chills and general malaise.\n He presented to Hospital with fever and left renal colic on\n . CT scan identified two stones obstructing the L ureter together\n with moderate hydroureteronephrosis. He was transferred to for\n further management.\n .H/O nephrolithiasis (Kidney Stones)\n Assessment:\n s/p left nephrosotomy tube placement on for hydronephrosis.\n Nephrostomy tube with 575ccs slightly pink output. Pt denies any pain\n and is afebrile. Hemodynamics stable. Foley cath in place with\n adequate hourly uo.\n Action:\n Nephrosotomy output followed closely as well as pt\ns pain level.\n Followed fever curve and administered antibiotics as ordered. Awating\n final results of cultures sent last noc.\n Response:\n Stable ovenoc and remains afebrile. Pt is pain free.\n Plan:\n Transfer to medical floor bed when available. Follow fluid balance\n closely. Follow recommendations of urology. Continue to assess pt\n pain level and medicate with ivp morphine as needed\n Pt is a&o x3. pleasant and cooperative. Has not required any o2 with rr\n high teens to low 20\ns and o2 sats> 93%. Lungs cta. Tolerating reg diet\n without c/o n/v . abd benign on exam. Has 2 piv\ns in place . pt\ns wife\n was called and is aware of pt\ns transfer to floor bed. At 1200 pt\n transferred to 1162 via wheelchair\n" }, { "category": "Physician ", "chartdate": "2125-06-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 632966, "text": "Chief Complaint: flank pain\n HPI:\n Mr. is a 69 year old male with history of bilateral renal stones\n s/p ESWL (extracorpeal shockwave lithotripsy) and with Dr.\n , self catheterizes at home, HTN, hyperlipidemia who presents\n from OSH with L ureteral obstructing stone. Renal U/S done on \n identified no hydronephrosis, 7mm RLP stone, 5mm LLP stone. On he\n developed L flank pain radiating to groin and one episode nausea,\n vomiting. The pain resolved spontaneously that evening, however it\n returned on . Associated with this he developed a fever, chills\n and general malaise. He denied diarrhea, abdominal pain and anorexia.\n He presented to Hospital with fever and left renal colic on\n . T 104.4 at OSH, BP 155/74, HR 102. UA positive for infection.\n CT scan identified two left UVJ stones measuring 9.4x4.2mm together\n with moderate hydroureteronephrosis. He was given Toradol, levaquin,\n zofran and IVF. He was transferred to for further management.\n .\n In the ED, vital signs were T 98.4, BP 90/54, HR 98, RR 20, O2 sat 97%\n on RA. SBP noted as low as nadir to 80/54, normally in 120-130s. He\n was given 4L NS with moderate response in blood pressure. He was given\n a dose of Ceftriaxone and Levofloxacin for broad coverage. He was seen\n by urology in the ED and plan for left nephrostomy tube in the AM. He\n is being admitted to ICU for closer monitoring in setting of infection\n and hypotension.\n .\n On arrival to the the patient is awake and alert. He is feeling\n well with no pain. The last time he experienced pain was in \n Hospital.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Allopurinol 300mg daily\n Atenolol 50mg daily\n ASA 81mg daily\n Simvastatin 20mg daily\n Synthyroid 88mcg daily\n MVI daily\n Past medical history:\n Family history:\n Social History:\n Nephrolithiasis s/p lithotripsy\n Renal atrophy on the right\n Gout on allopurinol\n Hypertension\n Urinary retention with daily catheterization (QID)\n Hyperlipidemia\n Hypothyroidism\n PSH:\n BL ESWL \n L ESWL \n He has two children who are healthy. He has no family history of\n kidney disease, hypertension, or kidney stones.\n Occupation: Retired teacher\n Drugs: None\n Tobacco: None\n Alcohol: Drinks \"strong\" 2x/week\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: Flank pain\n Genitourinary: Dysuria, Self catheterization\n Pain: No pain / appears comfortable\n Flowsheet Data as of 05:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 80 (79 - 80) bpm\n BP: 116/66(78) {115/66(78) - 116/72(80)} mmHg\n RR: 19 (18 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,003 mL\n PO:\n TF:\n IVF:\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,203 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, EOMI, MMM\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No murmurs\n appreciated.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles\n at bilateral bases, otherwise clear\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Back: No CVA tenderness bilaterally\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 195\n 12.5\n 126\n 0.9\n 19\n 21\n 104\n 3.8\n 136\n 35.7\n 11.9\n [image002.jpg]\n Other labs: Differential-Neuts:87, Band:8, Lymph:4, Mono:1, Eos:0,\n Lactic Acid:1.9\n Fluid analysis / Other labs: UA mod leuk, mod blood, tr protein, pos\n nit, >50 WBC, many bact\n Imaging: Renal US: 1. Kidneys of normal size, without\n hydronephrosis. Non-obstructing calculi.\n 2. Focal thickening of the bladder wall. Comparison with prior exams is\n recommended if available. Otherwise, further evaluation is recommended\n with cystoscopy.\n Microbiology: Blood and urine cultures pending\n Assessment and Plan\n Mr. is a 69 year old male with history of hypertension,\n hyperlipidemia, renal stones who presents from OSH with left\n obstructing renal stone and acute complicated pyelonephritis.\n .\n # Obstructing left renal stone in setting of acute complicated\n pyelonephritis, concern for early urosepsis given fevers, WBC count (8%\n bands) and hypotension. Per recent renal note, stones attributed to\n mild primary hyperparathyroidism vs secondary hyperparathyroidism. He\n had hypercalciuria on 24hr urine sample. Seen by urology in the ED.\n - Plan for left nephrostomy tube placement first thing in the AM with\n interventional radiology.\n - Continue broad spectrum antibiotics for complicated pyelonephritis\n given setting of obstruction as well as self catheterization.\n - Follow blood and urine cultures\n - NPO after MN for possible procedure\n - Foley in place\n - Pain management as needed\n morphine written PRN\n - 2 PIV in place. Consider CVL placement if hypotension, tachycardia.\n .\n # Hypotension: SBP 80s in the ED, received 4L NS with modest\n improvement in blood pressure. Elevated WBC count (8% bands), fever\n and obvious urinary source (UA w/ leuk, nit pos, many bact) concerning\n for early sepsis. Lactate within normal limits. On arrival to \n hemodynamically stable.\n - Fluid resuscitation as needed\n - Goal to keep MAP>65\n - Antibiotics to treat infection as above\n .\n # Urinary retention: Self catheterizes at home.\n - Foley in place\n .\n # Hypertension: Not an active issue currently.\n - Will hold beta blocker while patient is hypotensive\n .\n # Hyperlipidemia\n - Continue statin as per home regimen\n .\n # Gout:\n - Continue allopurinol\n .\n # Hypothyroidism\n - Continue synthroid\n - Recheck TSH\n .\n #FEN\n - NPO after midnight for procedure\n - replete lytes PRN\n .\n #ACCESS: PIV x2.\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient\n .\n #DISPO: ICU until procedure\n .\n ICU Care\n Nutrition:\n Comments: NPO after MN for possible procedure\n Glycemic Control:\n Lines:\n 18 Gauge - 04:54 AM\n 20 Gauge - 04:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2125-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 632967, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.4\nF - 06:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 39.1\nC (102.4\n HR: 111 (79 - 136) bpm\n BP: 156/65(89) {115/65(78) - 225/153(165)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,023 mL\n PO:\n TF:\n IVF:\n 23 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,223 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.23/51/69//-6\n PaO2 / FiO2: 69\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n 06:19 AM\n TCO2\n 22\n Other labs: Lactic Acid:3.5 mmol/L\n Assessment and Plan\n Mr. is a 69 year old male with history of hypertension,\n hyperlipidemia, renal stones who presents from OSH with left\n obstructing renal stone and acute complicated pyelonephritis.\n .\n #Sepsis: Secondary to complicated pyelonephritis; spiked temp to 102.4\n this AM. + Rigors, altered mental status, tachycardia. BP stable.\n Elevated to lactate. 8% bands on WBC counts.\n - Continue zosyn for empiric coverage\n - monitor wbc count\n - f/u cultures\n - demerol for rigors\n - IVFs prn for hypotension\n - Goal MAP greater than 65\n # Pyelonephritis: Obstructing left renal stone in setting of acute\n complicated pyelonephritis. Per recent renal note, stones attributed\n to mild primary hyperparathyroidism vs secondary hyperparathyroidism.\n He had hypercalciuria on 24hr urine sample. Seen by urology in the ED.\n - Plan for left nephrostomy tube placement this morningwith\n interventional radiology.\n - Continue broad spectrum antibiotics for complicated pyelonephritis\n given setting of obstruction as well as self catheterization.\n - Follow blood and urine cultures\n - NPO for procedure\n - Foley in place\n - Pain management as needed\n morphine written PRN\n - 2 PIV in place. Consider CVL placement if hypotension, tachycardia.\n .\n # Urinary retention: Self catheterizes at home.\n - Foley in place\n # Hypertension: Transiently hypertensive in setting of fevers and\n rigors. BP now normal\n - continue to hold bblocker in setting of sepsis\n # Hyperlipidemia\n - Continue statin as per home regimen\n .\n # Gout:\n - Continue allopurinol\n .\n # Hypothyroidism\n - Continue synthroid\n - Recheck TSH\n .\n #FEN\n - NPO for procedure\n - replete lytes PRN\n .\n #ACCESS: PIV x2.\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - bowel meds\n .\n #CODE: FULL\n #COMMUNICATION: patient\n .\n #DISPO: ICU until procedure\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:54 AM\n 20 Gauge - 04:55 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": "2125-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 632968, "text": "Mr. is a 69 year old male with history of hypertension,\n hyperlipidemia, renal stones who presents from OSH with left\n obstructing renal stone and acute complicated pylenophritis. Of note,\n he caths himself daily at home for residual urine. In EW he was\n hypotensive down to 80\ns and he rec\nd 4 liters NS with gradual\n stabilization of his bp. He was transferred to MICU for further\n management.\n On arrival he was in NAD. Afebrile with bp 100\ns and hr 80\ns. He\n became acutely rigorous with resultant hypertension (^220\n tachycardic (130\ns) with ^^ RR and bronchospastic wheezing. Unable to\n obtain sat due to severe agitation. He was tx\nd with Demerol 50mg iv ,\n Tylenol 650mg and an atrovent neb with improvement. ABG while taking\n neb showed hyoxia with poor ventilation (ph 7.23) and ^^ lactate. He\n was placed on 100% NRB with improvement, sats ^ mid to upper 90\n Team aware and in with pt during this episode. EKG done that showed no\n sign ischemic changes. Chest xray also done. He is currently with hr\n in the upper 90\ns and bp in the upper 90\ns. He is less agitated but\n still having ^^ restlessness. Son in during this episode and is cont\n to stay with pt.\n" }, { "category": "Physician ", "chartdate": "2125-06-22 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 632969, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 69 yr old male with hx of nephrolithiasis () and hx of urinary\n rtn, HTN, left flank pain to groin, n/v wednesday night. Awoke\n yesterday with fevers and chills - left flank pain. went to \n Hosp 104.4 155/74 hr 102 US + lek. CTA 2 left UBJ stones 9.4mm x 4.2 mm\n stones, moderate hydro. Toradol, levoquin and IVF tx to .\n Our ED 102 HR 90s BP 80/p, Rx with 4 L IVF, settled out to BP 110/70 Rx\n Ceftriz, Levoquin. urology consult recc urgent nephrostomy.\n 6 AM spiked to 102.4, rigoring, tachy to 130's, HTN to 220/115 - Rx\n wioth Zosyn, demerol, tylenol, atrovent nebs, mental staus was altered\n 7.23/51/69 lactate 3.5 (on 5L) Stat CXR (poor film) shows some\n interstitial edema.\n Tx to MICU for hemodynamic montoring.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n nephrolithisis\n gout\n HTN\n hypothyroidism\n hyperlipidemia\n Allopurinol. ASA, statin, synthroid\n Occupation: ret science teacher\n Drugs: none\n Tobacco: none\n Alcohol: 2 matinis a week\n Other: married\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Flowsheet Data as of 08:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.4\nC (99.4\n HR: 95 (79 - 136) bpm\n BP: 109/54(65) {96/54(65) - 225/153(165)} mmHg\n RR: 23 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,307 mL\n PO:\n TF:\n IVF:\n 307 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,367 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 97%\n ABG: 7.23/51/69/19/-6\n PaO2 / FiO2: 138\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 131 K/uL\n 36.0 %\n 11.8 g/dL\n 108 mg/dL\n 0.8 mg/dL\n 15 mg/dL\n 19 mEq/L\n 108 mEq/L\n 4.4 mEq/L\n 141 mEq/L\n 2.6 K/uL\n [image002.jpg]\n 05:39 AM\n 06:19 AM\n WBC\n 2.6\n Hct\n 36.0\n Plt\n 131\n Cr\n 0.8\n TC02\n 22\n Glucose\n 108\n Other labs: Band:8, Lactic Acid:3.5 mmol/L, Ca++:7.7 mg/dL, Mg++:1.5\n mg/dL, PO4:3.4 mg/dL\n Fluid analysis / Other labs: UA > 50 wbc\n Imaging: CXR with interstitial edema\n Microbiology: Blood Cx pending\n Urne cx pending\n Assessment and Plan\n 69 yr old man with sepsis secondary to obstructed renal stone\n 1. Sepsis : needs definitive Rx with nephrostomy tube, Rx with\n continued IVF and serial lactate. IVF for MAP less than 65\n : Zosyn currently, blood and urine cx pending. Call hospital to follow up cx\n : Rx with dose of VANCO while cx pending\n 2. Acid Base: Mixed resp and metabolic acidosis. Resp. etiology could\n be vol overload with pulm edema. and metabolic would be acidosis.\n 3. Access: 2 PIV,\n 4. Proph: PPI, SQ hep\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 04:54 AM\n 20 Gauge - 04:55 AM\n Comments:\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:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2125-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 632970, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.4\nF - 06:00 AM\n Spiked fever this AM. Associated with altered mental status,\n tachycardia, hypertension to 220/110, rigors and wheezing. Given zosyn,\n Tylenol, atrovent, Demerol with improvement. Mental status, heart rate,\n BP improved with resolution of fever.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 39.1\nC (102.4\n HR: 111 (79 - 136) bpm\n BP: 156/65(89) {115/65(78) - 225/153(165)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,023 mL\n PO:\n TF:\n IVF:\n 23 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,223 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.23/51/69//-6\n PaO2 / FiO2: 69\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 131\n 11.8\n 108\n 0.08\n 19\n 4.4\n 15\n 108\n 141\n 36\n 2.6\n [image002.jpg] ABG: 7.23/51/69 Lactate 3.5\n 06:19 AM\n TCO2\n 22\n Other labs: Lactic Acid:3.5 mmol/L\n Assessment and Plan\n Mr. is a 69 year old male with history of hypertension,\n hyperlipidemia, renal stones who presents from OSH with left\n obstructing renal stone and acute complicated pyelonephritis.\n .\n #Sepsis: Secondary to complicated pyelonephritis; spiked temp to 102.4\n this AM. + Rigors, altered mental status, tachycardia. BP stable.\n Elevated to lactate. 8% bands on WBC counts. Given potential urinary\n tract organisms, will add vanco to cover enterococcus and continue\n zosyn.\n - Continue zosyn for empiric coverage\n - Add vanco for Gram + coverage\n - monitor wbc count\n - f/u cultures\n - demerol for rigors\n - IVFs prn for hypotension\n - Goal MAP greater than 65\n # Pyelonephritis: Obstructing left renal stone in setting of acute\n complicated pyelonephritis. Per recent renal note, stones attributed\n to mild primary hyperparathyroidism vs secondary hyperparathyroidism.\n He had hypercalciuria on 24hr urine sample. Seen by urology in the ED.\n - Plan for left nephrostomy tube placement this morningwith\n interventional radiology.\n - Continue broad spectrum antibiotics for complicated pyelonephritis\n given setting of obstruction as well as self catheterization.\n - Follow blood and urine cultures\n - NPO for procedure\n - Foley in place\n - Pain management as needed\n morphine written PRN\n - 2 PIV in place. Consider CVL placement if hypotension, tachycardia.\n # Lactic acidosis: secondary to sepsis\n # Pulmonary edema: Likely secondary to acute diastolic dysfunction in\n setting of hypertensive urgency\n - Check ECHO\n - Monitor I/O: goal -500cc if BP tolerates\n .\n # Urinary retention: Self catheterizes at home.\n - Foley in place\n # Hypertension: Transiently hypertensive in setting of fevers and\n rigors. BP now normal\n - continue to hold bblocker in setting of sepsis\n # Hyperlipidemia\n - Continue statin as per home regimen\n .\n # Gout:\n - Continue allopurinol\n .\n # Hypothyroidism\n - Continue synthroid\n - Recheck TSH\n .\n #FEN\n - NPO for procedure\n - replete lytes PRN\n .\n #ACCESS: PIV x2.\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - bowel meds\n .\n #CODE: FULL\n #COMMUNICATION: patient\n .\n #DISPO: ICU until procedure\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:54 AM\n 20 Gauge - 04:55 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": "2125-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 632972, "text": "69 y/o M with a PMH significant for bilateral renal stones s/p\n extracorpeal shockwave lithotripsy in and self catheterizes\n at home, HTN & hyperlipidemia who presents from OSH with L ureteral\n obstructing stone. Renal U/S done on identified no\n hydronephrosis, 7mm RLP stone, 5mm LLP stone. On he developed L\n flank pain radiating to groin and one episode nausea, vomiting. The\n pain resolved spontaneously that evening, however it returned on .\n Associated with this he developed a fever, chills and general malaise.\n He presented to Hospital with fever and left renal colic on\n . CT scan identified two stones obstructing the L ureter together\n with moderate hydroureteronephrosis. He was transferred to for\n further management.\n Events:\n -L nephrostomy tube placed in IR w/o complication\n -OOB to chair and ambulated around Unit\n -Tolerating a regular diet\n .H/O nephrolithiasis (Kidney Stones)\n Assessment:\n L obstructing ureter persists\n Action:\n Nephrostomy tube placed\n Response:\n Nephrostomy continues to draing approx 50cc clear yellow/hr\n Plan:\n Urology to follow up w/ obstruction\n .H/O sepsis without organ dysfunction\n Assessment:\n Febrile to 102 prior to 0700 hypotensive to 85 systolic, w/ associated\n MS changes\n Action:\n Received Tylenol, Demerol, zosyn cefepime\n Response:\n Currently afebrile, A/O x 3\n Plan:\n Cont w/ abx tx. Will likely be called out to floor this evening/\n tomorrow morning.\n" }, { "category": "Nursing", "chartdate": "2125-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 632973, "text": "69 y/o M with a PMH significant for bilateral renal stones s/p\n extracorpeal shockwave lithotripsy in and self catheterizes\n at home, HTN & hyperlipidemia who presents from OSH with L ureteral\n obstructing stone. Renal U/S done on identified no\n hydronephrosis, 7mm RLP stone, 5mm LLP stone. On he developed L\n flank pain radiating to groin and one episode nausea, vomiting. The\n pain resolved spontaneously that evening, however it returned on .\n Associated with this he developed a fever, chills and general malaise.\n He presented to Hospital with fever and left renal colic on\n . CT scan identified two stones obstructing the L ureter together\n with moderate hydroureteronephrosis. He was transferred to for\n further management.\n .H/O nephrolithiasis (Kidney Stones)\n Assessment:\n S/P L Nepheostomy placement on for hydronephrosis.\n Action:\n Monitor Nephrostomy tube output.\n Response:\n Nephrostomy tube draining adequate amounts of pink tinged urine. Foley\n cath draining clear yellow urine. Denies pain. Remains afebrile.\n Plan:\n Cont. to monitor urine output. Rutine ICU care. f/u cx.\n" }, { "category": "Case Management ", "chartdate": "2125-06-22 00:00:00.000", "description": "Case Managment Initial Patient Assessment", "row_id": 632971, "text": "Insurance information\n Primary insurance: MEDICARE A B (HOSP MED INS)\n Secondary insurance: JH STATE/GIC INDEMNITY PLAN\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: Urinary catheters for self catheterization\n Functional Status / Home / Family Assessment:\n Pt. lives with his wife in E. on . he is independent\n with his ADL's. Mr. has an hx over the last 1.5 years of renal\n calculi with retention and occasionally self catheterizes.\n Primary Contact(s): (wife) or \n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended: Social Work\n Current plan: Undetermined\n Unclear what level oof services will be required on discharge. Case\n Management will follow for DC needs.\n Patient (s) to Discharge:\n None\n Patient discussed with multidisciplinary team: No\n" } ]

[ { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490149, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status -\n noted to have memory deficit and emotional lability but no agitation;\n oriented x 3, denies any pain. Moving all extremities. Patient received\n her cycle 2 of Methotrexate with leucovorin PO or IV ( patient has been\n getting IV leucovorin as rescue meds to prevent detrimental effect of\n methotrexate) on HD prior to MICU transfer\n for CVVHDF\n Action:\n CVVHDF initiated at 2130\n blood flow rate of 120cc/hr, citrate\n infusing at 180cc/hr; KCL at 20 cc/hr and calcium gluconate at 35\n cc/hr; continues with bicarb drip even after CVVHDF was started, will\n follow-up with Dr. if will remain on bicarb drip; Urine pH checked\n every time patient voids; continues on leucovorin IV q6hrs; Ativan 1\n mg PO given for for anxiety and insomnia. SW consult for coping\n CITRATE DECREASED TO 150CC/HR FORM 180, RESCUE LINE FLUSH INCREASED TO\n Q2HRS ( last given at 6 am) in setting of serum calcium increasing and\n ionized calcium decreasing\n renal fellow aware of changes made\n Response:\n Urine pH 8.0; stable vital signs - no nausea and vomiting; access\n pressure gets too negative with position changes, patient kept even\n I/O\ns; latest ionized calcium 0.91 and serum K of 4.4\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given due at 3 am\n ); lytes q6hrs 9-3-9-3 schedule; antiemetics with zofran prn;\n leucovorin PRN if urine PH falls below 7.5; plan to dc citrate if\n continues to show signs of citrate toxicity\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Chronic renal failure s/p kidney transplant: was on HD for about 8 hrs\n prior to admission at MICU; urine output 400-600cc/3-4 hrs\n Action:\n restarted CellCep yesterday; continue prednisone 4mg daily and sodium\n bicarb 1300 PO Q6 per transplant recs\n Response:\n BUN/creatinine 6/0.9 latest with am labs\n Plan:\n Continue CVVHDF\n" }, { "category": "Physician ", "chartdate": "2199-08-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 490058, "text": "TITLE:\n Chief Complaint: CNS lymphoma s/p kidney transplant requiring CCVH\n with methotrexate\n HPI:\n The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today. Of note, while out\n of the hospital the patient had been staying with her family and\n intermittently refusing medications. The patient reports that she feels\n like a burden on her parents and may want to live with sister.\n creatinine on admission today is 2.9 which is up from 2.1 at her\n previous admission. On transfer to the ICU, she is somewhat tearful\n and would like to go home but understands why she needs to be here. Pt\n has been feeling well physically, denies SOB/chest pain, denies\n n/v/d/f/c, denies dizziness/confusion, states that her urine output is\n unchanged from her normal output.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Other medications:\n Home medications:\n AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)\n ARANESP SURECLICK -POLYSORBATE - 100 mcg/0.5 mL Pen Injector -\n IM/Subq weekly\n ATENOLOL - (update) - 100 mg Tablet - 1 Tablet(s) by mouth once\n a day\n ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once\n a day\n CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth once a day\n ERGOCALCIFEROL (VITAMIN D2) [DRISDOL] - 50,000 unit Capsule - 1\n Capsule(s) by mouth qweek x3months\n FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1\n Tablet(s) by mouth once a day\n FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1\n (One) Tablet(s) by mouth as needed\n MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 2 Tablet(s) by\n mouth twice a day\n PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider: .\n - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by\n mouth once a day\n PICC LINE - - please discontinue PICC line once\n PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth once a day\n SEVELAMER HCL [RENAGEL] - (Prescribed by Other Provider) - 400\n mg Tablet - 2 Tablet(s) by mouth three times a day\n FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg\n Iron) Tablet - 1 Tablet(s) by mouth DAILY (Daily)\n SODIUM BICARBONATE - (Dose adjustment - no new Rx) - 650 mg\n Tablet - 3 Tablet(s) by mouth twice a day only taking 1300mg qd\n Past medical history:\n Family history:\n Social History:\n -IDDM diagnosed at 14 months\n -Hypertension\n -Crescentic glomerulonephritis at age 14 which progressed to renal\n failure, requiring dialysis s/p deceased donor renal transplant \n c/b graft rejection, s/p second cadaveric renal transplant , and\n s/p cadaveric kidney/pancreas transplant in , s/p bilateral\n nephrectomy of her native kidneys due to hypertension, on\n immunosuppression\n -s/p ligation of arteriovenous fistula, left antecubital space\n -Ventral/incisional hernias (times 4) s/p repair \n -Anemia\n -Polycystic ovarian syndrome\n -Chronic pancreatitis\n -Renal osteodystrophy\n Her grandfather had NIDDM and her great grandmother had IDDM.\n Occupation: Currently not working.\n Drugs: Denies\n Tobacco: Denies\n Alcohol: She drinks a glass of wine/month.\n Other: She has a boyfriend, ; lives with her mother but used to\n live with her sister. She has college education in early childhood\n development; worked as a nanny and as a kindergarten teacher.\n Review of systems:\n Negative except as noted in the HPI.\n Flowsheet Data as of 11:11 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 89 (89 - 92) bpm\n BP: 148/89(104) {127/84(94) - 154/104(112)} mmHg\n RR: 21 (13 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,064 mL\n PO:\n 50 mL\n TF:\n IVF:\n 1,014 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 464 mL\n Respiratory\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n GEN: Middle-aged female, alert and tearful.\n HEENT: some alopecia right parietal area, a small mouth sore present,\n MMM\n Neck: supple, no LAD\n CV: regular rhythm, 3/6 systolic murmur loudest at upper sternal border\n PULM: Patient is breathing comfortably. CTAB\n ABD: +BS, soft NTND\n EXT: no edema, extremities warm and well perfused, 2 + DP\n Neuro: CN II-XII grossly intact, sensation to light touch intact\n throughout. 5/5 strength in her upper and lower extremitites\n bilaterally.\n SKIN: Erythematous around Right subclavian Dialysis catheter site and\n Left sided PICC line site\n Labs / Radiology\n 566 K/uL\n 8.1 g/dL\n 109 mg/dL\n 0.8 mg/dL\n 6 mg/dL\n 34 mEq/L\n 105 mEq/L\n 4.0 mEq/L\n 145 mEq/L\n 24.7 %\n 6.0 K/uL\n [image002.jpg]\n \n 2:33 A10/7/ 08:09 PM\n \n 10:20 P10/7/ 08:10 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.0\n Hct\n 24.7\n Plt\n 566\n Cr\n 0.8\n Glucose\n 109\n Other labs: PT / PTT / INR:12.9/30.7/1.1, Ca++:7.9 mg/dL, Mg++:1.4\n mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2199-08-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 490059, "text": "TITLE:\n Chief Complaint: CNS lymphoma s/p kidney transplant requiring CCVH\n with methotrexate\n HPI:\n The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today. Of note, while out\n of the hospital the patient had been staying with her family and\n intermittently refusing medications. The patient reports that she feels\n like a burden on her parents and may want to live with sister.\n creatinine on admission today is 2.9 which is up from 2.1 at her\n previous admission. On transfer to the ICU, she is somewhat tearful\n and would like to go home but understands why she needs to be here. Pt\n has been feeling well physically, denies SOB/chest pain, denies\n n/v/d/f/c, denies dizziness/confusion, states that her urine output is\n unchanged from her normal output.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Other medications:\n Home medications:\n AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)\n ATENOLOL - (update) - 100 mg Tablet - 1 Tablet(s) by mouth once a day\n ATORVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day\n CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth once a day\n ERGOCALCIFEROL (VITAMIN D2) [DRISDOL] - 50,000 unit Capsule - 1\n Capsule(s) by mouth qweek x3months\n FOLIC ACID 1 mg Tablet - 1\n Tablet(s) by mouth once a day\n FUROSEMIDE -- 20 mg Tablet - 1\n (One) Tablet(s) by mouth as needed\n MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 2 Tablet(s) by\n mouth twice a day\n PANTOPRAZOLE - 40 mg Tablet, - 1 Tablet(s) by mouth once a day\n PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth once a day\n SEVELAMER HCL [RENAGEL] - 400\n mg Tablet - 2 Tablet(s) by mouth three times a day\n FERROUS SULFATE -- 325 mg (65 mg\n Iron) Tablet - 1 Tablet(s) by mouth DAILY\n SODIUM BICARBONATE -- 650 mg\n Tablet - 3 Tablet(s) by mouth twice a day only taking 1300mg qd\n Past medical history:\n Family history:\n Social History:\n -IDDM diagnosed at 14 months\n -Hypertension\n -Crescentic glomerulonephritis at age 14 which progressed to renal\n failure, requiring dialysis s/p deceased donor renal transplant \n c/b graft rejection, s/p second cadaveric renal transplant , and\n s/p cadaveric kidney/pancreas transplant in , s/p bilateral\n nephrectomy of her native kidneys due to hypertension, on\n immunosuppression\n -s/p ligation of arteriovenous fistula, left antecubital space\n -Ventral/incisional hernias (times 4) s/p repair \n -Anemia\n -Polycystic ovarian syndrome\n -Chronic pancreatitis\n -Renal osteodystrophy\n Her grandfather had NIDDM and her great grandmother had IDDM.\n Occupation: Currently not working.\n Drugs: Denies\n Tobacco: Denies\n Alcohol: She drinks a glass of wine/month.\n Other: She has a boyfriend, ; lives with her mother but used to\n live with her sister. She has college education in early childhood\n development; worked as a nanny and as a kindergarten teacher.\n Review of systems:\n Negative except as noted in the HPI.\n Flowsheet Data as of 11:11 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 89 (89 - 92) bpm\n BP: 148/89(104) {127/84(94) - 154/104(112)} mmHg\n RR: 21 (13 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,064 mL\n PO:\n 50 mL\n TF:\n IVF:\n 1,014 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 464 mL\n Respiratory\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n GEN: Middle-aged female, alert and tearful.\n HEENT: some alopecia right parietal area, a small mouth sore present,\n MMM\n Neck: supple, no LAD\n CV: regular rhythm, 3/6 systolic murmur loudest at upper sternal border\n PULM: Patient is breathing comfortably. CTAB\n ABD: +BS, soft NTND\n EXT: no edema, extremities warm and well perfused, 2 + DP\n Neuro: CN II-XII grossly intact, sensation to light touch intact\n throughout. 5/5 strength in her upper and lower extremitites\n bilaterally.\n SKIN: Erythematous around Right subclavian Dialysis catheter site and\n Left sided PICC line site\n Labs / Radiology\n 566 K/uL\n 8.1 g/dL\n 109 mg/dL\n 0.8 mg/dL\n 6 mg/dL\n 34 mEq/L\n 105 mEq/L\n 4.0 mEq/L\n 145 mEq/L\n 24.7 %\n 6.0 K/uL\n [image002.jpg]\n \n 2:33 A10/7/ 08:09 PM\n \n 10:20 P10/7/ 08:10 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.0\n Hct\n 24.7\n Plt\n 566\n Cr\n 0.8\n Glucose\n 109\n Other labs: PT / PTT / INR:12.9/30.7/1.1, Ca++:7.9 mg/dL, Mg++:1.4\n mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 39-year-old woman with pmh of type I diabetes, glomerulonephritis, s/p\n 2 kidney transplants and a double kidney and pancreas transplant in\n with EBV-associated B-cell CNS lymphoma.\n # EBV-Associated B-cell CNS Lymphoma: Initially diagnosed by biopsy in\n the setting of altered mental status. Currently receiving cycle 2 of\n Methotrexate with leucovorin.\n - leucovorin rescue started on the onc floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: Preominant memory impairment and emotional lability, and\n agitation. Seems unchanged since prior admission. Most likely \n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping.\n # Acute renal failure s/p kidney transplant: Creatinine increased from\n previous admission. differential includes ? not taking meds vs ? mtx\n effect vs other cause of ARF. Now that she has been on HD, Cr level\n has been lowered to 0.8. Pancreas working fine; diabetes no longer an\n issue.\n - per Transplant recs: restarted CellCep today; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n # Anemia: Hct of 24.7 which is within her recent baseline for Hct in\n the mid to high 20's. Likely secondary to recent chemo.\n - Trend Hct.\n - Continue ferrous sulfate.\n - Transfuse for Hct < 21.\n # Hypertension: Patient normotensive on arrival.\n - continue home regimen of atenolol 100 mg po daily and amlodipine 5mg\n daily\n # Diabtes type 1 s/p pancreas transplant: Patient does not require\n insulin as an outpatient since her transplant.\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI (on at home as with chronic prednisone)\n VAP:\n Comments:\n Communication: Comments: Patient, HCP is her mother and \n . Phone: Comments: home- .\n Code status: Full code\n Disposition: ICU for until off CVVHD\n" }, { "category": "Physician ", "chartdate": "2199-08-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 490061, "text": "TITLE:\n Chief Complaint: CNS lymphoma s/p kidney transplant requiring CCVH\n with methotrexate\n HPI:\n The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today. Of note, while out\n of the hospital the patient had been staying with her family and\n intermittently refusing medications. The patient reports that she feels\n like a burden on her parents and may want to live with sister.\n creatinine on admission today is 2.9 which is up from 2.1 at her\n previous admission. On transfer to the ICU, she is somewhat tearful\n and would like to go home but understands why she needs to be here. Pt\n has been feeling well physically, denies SOB/chest pain, denies\n n/v/d/f/c, denies dizziness/confusion, states that her urine output is\n unchanged from her normal output.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Other medications:\n Home medications:\n AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)\n ATENOLOL - (update) - 100 mg Tablet - 1 Tablet(s) by mouth once a day\n ATORVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day\n CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth once a day\n ERGOCALCIFEROL (VITAMIN D2) [DRISDOL] - 50,000 unit Capsule - 1\n Capsule(s) by mouth qweek x3months\n FOLIC ACID 1 mg Tablet - 1\n Tablet(s) by mouth once a day\n FUROSEMIDE -- 20 mg Tablet - 1\n (One) Tablet(s) by mouth as needed\n MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 2 Tablet(s) by\n mouth twice a day\n PANTOPRAZOLE - 40 mg Tablet, - 1 Tablet(s) by mouth once a day\n PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth once a day\n SEVELAMER HCL [RENAGEL] - 400\n mg Tablet - 2 Tablet(s) by mouth three times a day\n FERROUS SULFATE -- 325 mg (65 mg\n Iron) Tablet - 1 Tablet(s) by mouth DAILY\n SODIUM BICARBONATE -- 650 mg\n Tablet - 3 Tablet(s) by mouth twice a day only taking 1300mg qd\n Past medical history:\n Family history:\n Social History:\n -IDDM diagnosed at 14 months\n -Hypertension\n -Crescentic glomerulonephritis at age 14 which progressed to renal\n failure, requiring dialysis s/p deceased donor renal transplant \n c/b graft rejection, s/p second cadaveric renal transplant , and\n s/p cadaveric kidney/pancreas transplant in , s/p bilateral\n nephrectomy of her native kidneys due to hypertension, on\n immunosuppression\n -s/p ligation of arteriovenous fistula, left antecubital space\n -Ventral/incisional hernias (times 4) s/p repair \n -Anemia\n -Polycystic ovarian syndrome\n -Chronic pancreatitis\n -Renal osteodystrophy\n Her grandfather had NIDDM and her great grandmother had IDDM.\n Occupation: Currently not working.\n Drugs: Denies\n Tobacco: Denies\n Alcohol: She drinks a glass of wine/month.\n Other: She has a boyfriend, ; lives with her mother but used to\n live with her sister. She has college education in early childhood\n development; worked as a nanny and as a kindergarten teacher.\n Review of systems:\n Negative except as noted in the HPI.\n Flowsheet Data as of 11:11 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 89 (89 - 92) bpm\n BP: 148/89(104) {127/84(94) - 154/104(112)} mmHg\n RR: 21 (13 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,064 mL\n PO:\n 50 mL\n TF:\n IVF:\n 1,014 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 464 mL\n Respiratory\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n GEN: Middle-aged female, alert and tearful.\n HEENT: some alopecia right parietal area, a small mouth sore present,\n MMM\n Neck: supple, no LAD\n CV: regular rhythm, 3/6 systolic murmur loudest at upper sternal border\n PULM: Patient is breathing comfortably. CTAB\n ABD: +BS, soft NTND\n EXT: no edema, extremities warm and well perfused, 2 + DP\n Neuro: CN II-XII grossly intact, sensation to light touch intact\n throughout. 5/5 strength in her upper and lower extremitites\n bilaterally.\n SKIN: Erythematous around Right subclavian Dialysis catheter site and\n Left sided PICC line site\n Labs / Radiology\n 566 K/uL\n 8.1 g/dL\n 109 mg/dL\n 0.8 mg/dL\n 6 mg/dL\n 34 mEq/L\n 105 mEq/L\n 4.0 mEq/L\n 145 mEq/L\n 24.7 %\n 6.0 K/uL\n [image002.jpg]\n \n 2:33 A10/7/ 08:09 PM\n \n 10:20 P10/7/ 08:10 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.0\n Hct\n 24.7\n Plt\n 566\n Cr\n 0.8\n Glucose\n 109\n Other labs: PT / PTT / INR:12.9/30.7/1.1, Ca++:7.9 mg/dL, Mg++:1.4\n mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 39-year-old woman with pmh of type I diabetes, glomerulonephritis, s/p\n 2 kidney transplants and a double kidney and pancreas transplant in\n with EBV-associated B-cell CNS lymphoma.\n # EBV-Associated B-cell CNS Lymphoma: Initially diagnosed by biopsy in\n the setting of altered mental status. Currently receiving cycle 2 of\n Methotrexate with leucovorin.\n - leucovorin rescue started on the onc floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: Preominant memory impairment and emotional lability, and\n agitation. Seems unchanged since prior admission. Most likely \n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping.\n # Acute renal failure s/p kidney transplant: Creatinine increased from\n previous admission. differential includes ? not taking meds vs ? mtx\n effect vs other cause of ARF. Now that she has been on HD, Cr level\n has been lowered to 0.8. Pancreas working fine; diabetes no longer an\n issue.\n - per Transplant recs: restarted CellCep today; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n # Anemia: Hct of 24.7 which is within her recent baseline for Hct in\n the mid to high 20's. Likely secondary to recent chemo.\n - Trend Hct.\n - Continue ferrous sulfate.\n - Transfuse for Hct < 21.\n # Hypertension: Patient normotensive on arrival.\n - continue home regimen of atenolol 100 mg po daily and amlodipine 5mg\n daily\n # Diabtes type 1 s/p pancreas transplant: Patient does not require\n insulin as an outpatient since her transplant.\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI (on at home as with chronic prednisone)\n VAP:\n Comments:\n Communication: Comments: Patient, HCP is her mother and \n . Phone: Comments: home- .\n Code status: Full code\n Disposition: ICU for until off CVVHD\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: 39 F who is transferred to the for renal\n replacement therapy to aid in clearance of MTX. She apparently was very\n emotional earlier in the day, but on my exam was much better. She is\n hemodynamically stable on CVVH, her cardiac exam is WNL, lungs are\n clear, abdomen is soft and nontender, and extremities show no edema.\n Vital signs were reviewed on the flowsheet.\n Agree with plan to continue RRT and follow MTX levels.\n Remainder of plan as outlined above.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:19 AM ------\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490116, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status -\n noted to have memory deficit and emotional lability but no agitation;\n oriented x 3, denies any pain. Moving all extremities. Patient received\n her cycle 2 of Methotrexate with leucovorin PO or IV ( patient has been\n getting IV leucovorin as rescue meds to prevent detrimental effect of\n methotrexate) on HD prior to MICU transfer\n for CVVHDF\n Action:\n CVVHDF initiated at 2130\n blood flow rate of 120cc/hr, citrate\n infusing at 180cc/hr; KCL at 20 cc/hr and calcium gluconate at 35\n cc/hr; continues with bicarb drip even after CVVHDF was started, will\n follow-up with Dr. if will remain on bicarb drip; Urine pH checked\n every time patient voids; continues on leucovorin IV q6hrs; Ativan 1\n mg PO given for for anxiety and insomnia. SW consult for coping\n Response:\n Urine pH 8.0; stable vital signs - no nausea and vomiting; access\n pressure gets too negative with position changes, patient kept even\n I/O\ns; latest ionized calcium 0.91 and serum K of 4.4\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given due at 3 am\n ); lytes q6hrs 9-3-9-3 schedule; antiemetics with zofran prn;\n leucovorin PRN if urine PH falls below 7.5\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Chronic renal failure s/p kidney transplant: was on HD for about 8 hrs\n prior to admission at MICU; urine output 400-600cc/3-4 hrs\n Action:\n restarted CellCep yesterday; continue prednisone 4mg daily and sodium\n bicarb 1300 PO Q6 per transplant recs\n Response:\n BUN/creatinine 6/0.9 latest with am labs\n Plan:\n Continue CVVHDF\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490104, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status -\n noted to have memory deficit and emotional lability but no agitation;\n oriented x 3, denies any pain. Moving all extremities. Patient received\n her cycle 2 of Methotrexate with leucovorin PO or IV ( patient has been\n getting IV leucovorin as rescue meds to prevent detrimental effect of\n methotrexate) on HD prior to MICU transfer\n for CVVHDF\n Action:\n CVVHDF initiated at 2130\n blood flow rate of 120cc/hr, citrate\n infusing at 180cc/hr; KCL at 20 cc/hr and calcium gluconate at 35\n cc/hr; Urine pH checked every time patient voids; continues on\n leucovorin IV q6hrs; Ativan 1 mg PO given for for anxiety and\n insomnia. SW consult for coping\n Response:\n Urine pH 8.5; no nausea and vomiting; access pressure gets too negative\n with position changes, kept patient even I/O\ns; latest ionized calcium\n 0.91 and serum K of 4.4\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given ( 3 am\n ); lytes q6hrs 9-3-9-3 schedule; antiemetics with zofran prn;\n leucovorin PRN if urine PH falls below 7.5\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Chronic renal failure s/p kidney transplant: creatinine trending up\n latest 0.8 as of last night\n was on HD for about 8 hrs prior to\n admission at MICU; urine output 400-600cc/3-4 hrs\n Action:\n restarted CellCep yesterday; continue prednisone 4mg daily and sodium\n bicarb 1300 PO Q6 per transplant recs\n Response:\n Plan:\n Continue CVVHDF\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490107, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status -\n noted to have memory deficit and emotional lability but no agitation;\n oriented x 3, denies any pain. Moving all extremities. Patient received\n her cycle 2 of Methotrexate with leucovorin PO or IV ( patient has been\n getting IV leucovorin as rescue meds to prevent detrimental effect of\n methotrexate) on HD prior to MICU transfer\n for CVVHDF\n Action:\n CVVHDF initiated at 2130\n blood flow rate of 120cc/hr, citrate\n infusing at 180cc/hr; KCL at 20 cc/hr and calcium gluconate at 35\n cc/hr; Urine pH checked every time patient voids; continues on\n leucovorin IV q6hrs; Ativan 1 mg PO given for for anxiety and\n insomnia. SW consult for coping\n Response:\n Urine pH 8.5; no nausea and vomiting; access pressure gets too negative\n with position changes, kept patient even I/O\ns; latest ionized calcium\n 0.91 and serum K of 4.4\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given ( 3 am\n ); lytes q6hrs 9-3-9-3 schedule; antiemetics with zofran prn;\n leucovorin PRN if urine PH falls below 7.5\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Chronic renal failure s/p kidney transplant: was on HD for about 8 hrs\n prior to admission at MICU; urine output 400-600cc/3-4 hrs\n Action:\n restarted CellCep yesterday; continue prednisone 4mg daily and sodium\n bicarb 1300 PO Q6 per transplant recs\n Response:\n BUN/creatinine 6/0.9 latest with am labs\n Plan:\n Continue CVVHDF\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490094, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status.\n Currently receiving cycle 2 of Methotrexate with leucovorin PO or IV (\n patient has been getting IV leucovorin ) as rescue meds started on\n 7South per Dr. \n Action:\n Urine pH checked every time patient voids; continues on leucovorin\n q6hrs; CVVHDF initiated at 2130\n blood flow rate of 120cc/hr, citrate\n infusing at 180cc/hr; KCL at 20 cc/hr and calcium gluconate at 35\n cc/hr\n Response:\n Urine pH 8.5; no nausea and vomiting; access pressure gets too negative\n with position changes, kept patient even I/O\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given ( 3 am\n ); lytes q6hrs 9-3-9-3 schedule; antiemetics with zofran prn;\n leucovorin PRN if urine PH falls below 7.5\n # Psych: Preominant memory impairment and emotional lability, and\n agitation. Seems unchanged since prior admission. Most likely \n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping.\n # Acute renal failure s/p kidney transplant: Creatinine increased from\n previous admission. differential includes ? not taking meds vs ? mtx\n effect vs other cause of ARF. Now that she has been on HD, Cr level\n has been lowered to 0.8. Pancreas working fine; diabetes no longer an\n issue.\n - per Transplant recs: restarted CellCep today; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490098, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status.\n Currently receiving cycle 2 of Methotrexate with leucovorin PO or IV (\n patient has been getting IV leucovorin ) as rescue meds started on\n 7South per Dr. ; noted to have memory impairment and emotional\n lability, but no agitation most likely lymphoma.\n Action:\n Urine pH checked every time patient voids; continues on leucovorin\n q6hrs; CVVHDF initiated at 2130\n blood flow rate of 120cc/hr, citrate\n infusing at 180cc/hr; KCL at 20 cc/hr and calcium gluconate at 35\n cc/hr; Ativan 1 mg PO given for for anxiety and insomnia. SW consult\n for coping\n Response:\n Urine pH 8.5; no nausea and vomiting; access pressure gets too negative\n with position changes, kept patient even I/O\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given ( 3 am\n ); lytes q6hrs 9-3-9-3 schedule; antiemetics with zofran prn;\n leucovorin PRN if urine PH falls below 7.5\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Chronic renal failure s/p kidney transplant: creatinine trending up\n latest 0.8 as of last night\n was on HD for about 8 hrs prior to\n admission at MICU; urine output 400-600cc/3-4 hrs\n Action:\n restarted CellCep yesterday; continue prednisone 4mg daily and sodium\n bicarb 1300 PO Q6 per transplant recs\n Response:\n Plan:\n Continue CVVHDF\n" }, { "category": "Nutrition", "chartdate": "2199-08-30 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 490512, "text": "Subjective\n Patient with emesis and , denies poor appetite\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 58.4 kg\n 25\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45 kg\n 129%\n 48 kg\n kg\n %\n Diagnosis: lymphoma\n PMHx: DM1, glomerulonephritis, s/p 2 kidney transplants ( and\n ), s/p double kidney and pancreas transplant (), PCOS, Bcell\n CNS lymphoma, chronic pancreatitis\n Food allergies and intolerances: none noted\n Pertinent medications: prednisone, calcitriol, renagel, ferrous\n sulfate, others noted\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 10:11 AM\n BUN\n 11 mg/dL\n 03:01 AM\n Creatinine\n 0.9 mg/dL\n 03:01 AM\n Sodium\n 137 mEq/L\n 10:11 AM\n Potassium\n 4.2 mEq/L\n 10:11 AM\n Chloride\n 108 mEq/L\n 10:11 AM\n TCO2\n 21 mEq/L\n 10:11 AM\n Calcium non-ionized\n 8.6 mg/dL\n 10:11 AM\n Phosphorus\n 2.1 mg/dL\n 10:11 AM\n Ionized Calcium\n 1.17 mmol/L\n 10:30 AM\n Magnesium\n 2.0 mg/dL\n 10:11 AM\n Current diet order / nutrition support: Regular diet\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: ?poor PO intake and emesis\n Estimated Nutritional Needs\n Calories: 1200-1440 (BEE x or / 25-30 cal/kg)\n Protein: 57-72 (1.2-1.5 while on CRRT g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Specifics:\n 39 year old female s/p 2 kidney transplants and s/p double kidney and\n pancreas transplant admitted for methotrexate administration requiring\n CVVHD. Patient is at some nutritional risk d/t diagnosis. Will follow\n PO intake and further episodes of n/v.\n Medical Nutrition Therapy Plan - Recommend the Following\n c/w diet as ordered\n If not able to meet nutritional needs, can consider\n nutrition support\n Will follow closely\n 12:00 PM\n" }, { "category": "Physician ", "chartdate": "2199-08-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 490518, "text": "Chief Complaint: Renal failure, lymphoma, anemia\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 Continued on CVVH through the day yesterday. Hemodynamics stable. Creat\n and electrolytes normal.\n MTX level this AM is below the threshold for stopping CVVH.\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:11 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 97 (84 - 104) bpm\n BP: 165/95(114) {130/75(93) - 178/110(128)} mmHg\n RR: 32 (17 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,842 mL\n 3,907 mL\n PO:\n 2,400 mL\n 420 mL\n TF:\n IVF:\n 8,442 mL\n 3,487 mL\n Blood products:\n Total out:\n 11,150 mL\n 4,830 mL\n Urine:\n 4,425 mL\n 1,660 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -308 mL\n -923 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Cushingoid\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : Clear anterior and lateral, No(t) Crackles : ,\n No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent :\n , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent edema, Left lower\n extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 524 K/uL\n 117 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 11 mg/dL\n 108 mEq/L\n 137 mEq/L\n 26.4 %\n 8.7 K/uL\n [image002.jpg]\n 08:09 PM\n 08:10 PM\n 03:07 AM\n 09:02 AM\n 03:00 PM\n 09:02 PM\n 12:00 AM\n 03:01 AM\n 10:11 AM\n WBC\n 6.0\n 5.9\n 8.7\n Hct\n 24.7\n 25.6\n 26.4\n Plt\n 566\n 505\n 524\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 109\n 108\n 95\n 134\n 114\n 115\n 132\n 117\n Other labs: PT / PTT / INR:11.6/24.7/1.0, ALT / AST:89/76, Alk Phos / T\n Bili:76/0.3, LDH:327 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n ANEMIA\n -------------------\n Doing well. MTX level down. Should be able to stop CVVH today.\n Electrolytes and creat normal.\n Hct stable. No evidence of active bleeding. Not at transfusion\n threshold.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments: VAP protocol not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :D/C Home\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490089, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) EBV-Associated B-cell\n CNS Lymphoma\n Assessment:\n Initially diagnosed by biopsy in the setting of altered mental status.\n Currently receiving cycle 2 of Methotrexate with leucovorin PO or IV (\n patient has been getting IV leucovorin ) as rescue meds started on\n 7South per Dr. \n Action:\n Urine pH checked every time patient voids; continues on leucovorin\n q6hrs; CVVHDF started at 2130 -\n Response:\n Urine pH 8.5; no nausea and vomiting\n Plan:\n Metotrexate level 48^th hrs post 2^nd cycle dose was given ( 3 am )\n .\n - leucovorin rescue started on the onc floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: Preominant memory impairment and emotional lability, and\n agitation. Seems unchanged since prior admission. Most likely \n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping.\n # Acute renal failure s/p kidney transplant: Creatinine increased from\n previous admission. differential includes ? not taking meds vs ? mtx\n effect vs other cause of ARF. Now that she has been on HD, Cr level\n has been lowered to 0.8. Pancreas working fine; diabetes no longer an\n issue.\n - per Transplant recs: restarted CellCep today; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n" }, { "category": "Nursing", "chartdate": "2199-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490381, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n B cell CNS lymphoma, s/p treatment w/methotrexate ( cycles),\n requiring CVVH for renal clearance. Last MTX level 0.34 w/goal of\n <0.1urine PH =>8. Bun/Cr wnl. Voiding adequate amnt. Denies pain.\n Action:\n Continue CVVH until goal MTX<0.1, urine Ph check w/each void. CVVH labs\n q6hr. Leucovorin rescue given ASDIR, bicarb gtt at 150cc/hr and po q6h.\n MTX levels . Renal and onc follows. Patient off citrate relative\n hypocalcemia earlier yesterday. Frequent system flushes to avoid system\n clotting (q1-2hr)\n Response:\n Ongoing AM MTX level pending\n Plan:\n Continue to monitor renal function and drug levels, f/u renal and onc\n recs.\n Neuro: alert oriented, follows commands, frequently sobbing and\ndoes\n not want to be on a machine anymore\n. Wants to be d/c so she can attend\n family function. SW involved to help w/cooping. Started on celexa and\n ativan PRN.\n Resp: on RA sata at high 90\ns. B/L LS clear. Denies resp distress.\n Cardio: B/P in 140-160\ns hr in 90\ns on metoprolol TID and amlodipine.\n Peripheral pulses present, no edema noted.\n GI: abd soft non tender, positive for BS. BM earlier yesterday. On\n regular renal diet. Denies poor appetite, nausea. However at 0200am lg\n amnt of emesis\n mostly food and water in content. Zofran given w/good\n effect. .\n GU: voiding adequate amnt, using bed pan. Urine PH =>8.0\n IV access: LT picc and RT HD cath, both are reddened at the site of the\n insertion. Team aware. Will follow for now.\n Social: patient is a FULL CODE> can be c/o when off CRRT.\n" }, { "category": "Nursing", "chartdate": "2199-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490604, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n CRRT stopped after methotrexate level 0.08. Voiding adequate amounts\n light colored urine.\n Action:\n CRRT stopped. Instructed to stop cellcept when discharged\n Response:\n Stable\n Plan:\n Discharged to home. Faxed discharge information to Genvita. Dr.\n will phone pt & instruct her where she will have her\n dialysis catheter flushed 2X every week\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Methotrexate 0.08. On leucovorin. CRRT d/cd. Temp 100.1 PO this\n afternoon. Both PICC & dialysis catheter insertion sites reddened,\n erythmatous\n Action:\n Dr aware of temp. Dietary restrictions d/c\n Response:\n Stable. Low grade temp, OK to discharge home.\n Plan:\n Discharged to home. Belongings sent home with pt. Leucovorin stopped\n today. Pt aware. VNA will follow up fro PICC line catheter flushes, dsg\n changes. Pt will follow up with Dr. for follow up and treatment\n plan.\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490083, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490304, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Continued on CRRT, alarms this morning for low access pressure and\n return pressure. Blood flow rate increased from 120 to 150 w/little\n effect, continued to alarm and blood flow rate increase to 250ml/min\n w/good effect. Citrate infusion stopped as well d/t hypocalcemia.\n Noting clots @ bottom of filter and small amount at top w/rescue\n flushes. Dialysis catheter site red, had small amt old blood drainage.\n Dressing changed and renal team assessed site @ bedside. PICC insertion\n site red as well, dressing changed today. Hypertensive to 170s,\n atenolol changed to metoprolol.\n Action:\n Blood flow rate increased to facilitate optimal pressures w/CRRT.\n Response:\n CRRT running without difficulty at present, small increase in amount of\n small clots @ filter after citrate stopped.\n Plan:\n CRRT as ordered. Monitor access sites, mark erythematic borders w/skin\n marker @ next dressing changes to better monitor the extent of\n erythema.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Emotionally labile, anxious, threatened to leave this morning. This\n afternoon continued to cry because she\nll needs CRRT overnight, wants\n to leave tomorrow for (which her sister says they can\n attend on Saturday). Patient reports frustration over being forced to\n remain in bed. Sister visited today, spoke w/social work as\n well. Requested that patient to be started on antidepressant to help\n w/mood stability. MTX level 1.7, cont w/leukovorin as prescribed, given\n IV as patient vomited this morning. Await 1500 MTX level.\n Action:\n Emotional support offered, patient appears to respond to 1:1 time spent\n @ bedside and speaking w/mother over the phone. Medicated x 1 w/.5mg PO\n ativan @ 1530 after renal MD recommended taking this to patient\n (patient refused this morning). Started on celexa today for apparent\n depression.\n Response:\n Ativan w/some effect, appeared to help patient to sleep. Needs\n continual emotional support and reminder that this is the course for\n her treatment of lymphoma.\n Plan:\n Cont to support emotionally. Ativan as directed. Social service and\n case management following.\n" }, { "category": "Social Work", "chartdate": "2199-08-29 00:00:00.000", "description": "Social Work Progress Note", "row_id": 490234, "text": "Pt referred by Dr. . Spoke to pt\ns mother on telephone.\n Met with pt and sister, . reports, and mother confirms,\n that pt has been very emotionally labile the last few months. Pt\n reports she is quite upset that her youngest sister is pregnant which\n is a reminder to her that she can never have children. Mother reports\n that at time of last kidney transplant, a hernia repair was needed and\n not done. Mother states that the kidney MD (who is no longer here) told\n the pt that the hernia repair could be done at her next kidney\n transplant. Mother states pt became very depressed by the certaintly\n expressed that she would need a transplant in the future.\n Mother and sister are requesting for pt be prescribed an antidepressant\n to stabilize her moods.\n Mother states that the comes weekly for PICC care. Mother has been\n taught how to flush it which she does. Mother also organizes all her\n medications though pt is trying to learn to do it. Pt has been coming\n to 7F for pheresis care. Mother requests that care be transferred\n to the transplant center in or to . Will call\n transplant coordinator with this request. Plan is for pt to go to apt\n in over weekend and to go to during the week. Spoke\n with RN Case Manager, (/#) and provided information.\n She will check on and discharge plans with pt\ns mother.\n , LICSW /\n" }, { "category": "Nursing", "chartdate": "2199-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490376, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n B cell CNS lymphoma, s/p treatment w/metotraxate ( cycles),\n requiring CVVH for renal clearance. Last MTX level 0.34. W/goal of\n <0.1urine PH =>8. Bun/Cr wnl. Voiding adequate amnt. Denies pain.\n Action:\n Continue CVVH until goal MTX<0.1, urine Ph check w/each void. CVVH labs\n q6hr. Leucovorin rescue given ASDIR, bicarb gtt at 150cc/hr and po q6h.\n MTX levels . Renal and onc follows. Patient off citrate relative\n hypocalcemia earlier yesterday. Frequent system flushes to avoid system\n clotting (q1-2hr)\n Response:\n Ongoing AM MTX level pending\n Plan:\n Continue to monitor renal function and drug levels, f/u renal and onc\n recs.\n Neuro: alert oriented, follows commands, frequently sobbing and\ndoes\n not want to be on a machine anymore\n. Wants to be d/c so she can attend\n family function. SW involved to help w/cooping. Started on celexa and\n ativan PRN.\n Resp: on RA sata at high 90\ns. B/L LS clear. Denies resp distress.\n Cardio: B/P in 140-160\ns hr in 90\ns on metoprolol TID and amlodipine.\n Peripheral pulses present, no edema noted.\n GI: abd soft non tender, positive for BS. BM earlier yesterday. On\n Regular renal diet. Denies poor appetite, nausea. However at 0200am lg\n amnt of emesis\n mostly food and water in content. Zofran given w/good\n effect. .\n GU: voiding adequate amnt, using bed pan. PH =>8.0\n IV access: LT picc and RT HD cath, both are reddened at the site of the\n insertion. Team aware. Will follow for now.\n Social: patient is a FULL CODE> can be c/o when off CRRT.\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490271, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Continued on CRRT, alarms this morning for low access pressure and\n return pressure. Blood flow rate increased from 120 to 150 w/little\n effect, continued to alarm and blood flow rate increase to 250ml/min\n w/good effect. Citrate infusion stopped as well d/t hypocalcemia.\n Noting clots @ bottom of filter and small amount at top w/rescue\n flushes. Dialysis catheter site red, had small amt old blood drainage.\n Dressing changed and renal team assessed site @ bedside. PICC insertion\n site red as well, dressing changed today.\n Action:\n Blood flow rate increased to facilitate optimal pressures w/CRRT.\n Response:\n CRRT running without difficulty at present, small increase in amount of\n small clots @ filter after citrate stopped.\n Plan:\n CRRT as ordered. Monitor access sites, mark erythematic borders w/skin\n marker @ next dressing changes to better monitor the extent of\n erythema.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Emotionally labile, anxious, threatened to leave this morning. This\n afternoon continued to cry because she\nll needs CRRT overnight, wants\n to leave tomorrow for (which her sister says they can\n attend on Saturday). Patient reports frustration over being forced to\n remain in bed. Sister visited today, spoke w/social work as\n well. Requested that patient to be started on antidepressant to help\n w/mood stability. Methyltrexate level 1.7, cont w/leukovorin as\n prescribed, given IV as patient vomited this morning. Await 1500\n methyltrexate level.\n Action:\n Emotional support offered, patient appears to respond to 1:1 time spent\n @ bedside and speaking w/mother over the phone. Medicated x 1 w/.5mg PO\n ativan @ 1530 after renal MD recommended taking this to patient\n (patient refused this morning). Started on celexa today for apparent\n depression.\n Response:\n Ativan w/some effect, appeared to help patient to sleep. Needs\n continual emotional support and reminder that this is the course for\n her treatment of lymphoma.\n Plan:\n Cont to support emotionally. Social service and case management\n following.\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490272, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Continued on CRRT, alarms this morning for low access pressure and\n return pressure. Blood flow rate increased from 120 to 150 w/little\n effect, continued to alarm and blood flow rate increase to 250ml/min\n w/good effect. Citrate infusion stopped as well d/t hypocalcemia.\n Noting clots @ bottom of filter and small amount at top w/rescue\n flushes. Dialysis catheter site red, had small amt old blood drainage.\n Dressing changed and renal team assessed site @ bedside. PICC insertion\n site red as well, dressing changed today.\n Action:\n Blood flow rate increased to facilitate optimal pressures w/CRRT.\n Response:\n CRRT running without difficulty at present, small increase in amount of\n small clots @ filter after citrate stopped.\n Plan:\n CRRT as ordered. Monitor access sites, mark erythematic borders w/skin\n marker @ next dressing changes to better monitor the extent of\n erythema.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Emotionally labile, anxious, threatened to leave this morning. This\n afternoon continued to cry because she\nll needs CRRT overnight, wants\n to leave tomorrow for (which her sister says they can\n attend on Saturday). Patient reports frustration over being forced to\n remain in bed. Sister visited today, spoke w/social work as\n well. Requested that patient to be started on antidepressant to help\n w/mood stability. Methyltrexate level 1.7, cont w/leukovorin as\n prescribed, given IV as patient vomited this morning. Await 1500\n methyltrexate level.\n Action:\n Emotional support offered, patient appears to respond to 1:1 time spent\n @ bedside and speaking w/mother over the phone. Medicated x 1 w/.5mg PO\n ativan @ 1530 after renal MD recommended taking this to patient\n (patient refused this morning). Started on celexa today for apparent\n depression.\n Response:\n Ativan w/some effect, appeared to help patient to sleep. Needs\n continual emotional support and reminder that this is the course for\n her treatment of lymphoma.\n Plan:\n Cont to support emotionally. Social service and case management\n following.\n" }, { "category": "Physician ", "chartdate": "2199-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490170, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n DIALYSIS CATHETER - START 07:00 PM\n - Emotional\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./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 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.2\nC (97.2\n HR: 88 (78 - 92) bpm\n BP: 159/91(107) {127/74(90) - 159/104(112)} mmHg\n RR: 19 (13 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,458 mL\n 3,897 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 1,408 mL\n 3,797 mL\n Blood products:\n Total out:\n 987 mL\n 3,745 mL\n Urine:\n 600 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 471 mL\n 152 mL\n Respiratory support\n SpO2: 98%\n ABG: ///26/\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 505 K/uL\n 8.2 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 107 mEq/L\n 143 mEq/L\n 25.6 %\n 5.9 K/uL\n [image002.jpg]\n 08:09 PM\n 08:10 PM\n 03:07 AM\n WBC\n 6.0\n 5.9\n Hct\n 24.7\n 25.6\n Plt\n 566\n 505\n Cr\n 0.8\n 0.9\n Glucose\n 109\n 108\n Other labs: PT / PTT / INR:12.2/25.0/1.0, Ca++:8.6 mg/dL, Mg++:2.3\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 39-year-old woman with pmh of type I diabetes, glomerulonephritis, s/p\n 2 kidney transplants and a double kidney and pancreas transplant in\n with EBV-associated B-cell CNS lymphoma.\n # EBV-Associated B-cell CNS Lymphoma: Initially diagnosed by biopsy in\n the setting of altered mental status. Currently receiving cycle 2 of\n Methotrexate with leucovorin.\n - leucovorin rescue started on the onc floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: Preominant memory impairment and emotional lability, and\n agitation. Seems unchanged since prior admission. Most likely \n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping.\n # Acute renal failure s/p kidney transplant: Creatinine increased from\n previous admission. differential includes ? not taking meds vs ? mtx\n effect vs other cause of ARF. Now that she has been on HD, Cr level\n has been lowered to 0.8. Pancreas working fine; diabetes no longer an\n issue.\n - per Transplant recs: restarted CellCep today; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n # Anemia: Hct of 24.7 which is within her recent baseline for Hct in\n the mid to high 20's. Likely secondary to recent chemo.\n - Trend Hct.\n - Continue ferrous sulfate.\n - Transfuse for Hct < 21.\n # Hypertension: Patient normotensive on arrival.\n - continue home regimen of atenolol 100 mg po daily and amlodipine 5mg\n daily\n # Diabtes type 1 s/p pancreas transplant: Patient does not require\n insulin as an outpatient since her transplant.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2199-08-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 490191, "text": "Chief Complaint: Chronic renal failure, lymphoma\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 on CVVH overnight. Cellcept restarted. No dyspnea. No\n hemodynamic problems. Oxygen saturation excellent without supplemental\n oxygen.\n Getting bicarb infusion to protect renal tubules.\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n DIALYSIS CATHETER - START 07:00 PM\n History obtained from Medical records\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Other medications:\n prednisone, amlodipine, iron, sodium bicarb, leukovorin, heparin sc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 94 (78 - 94) bpm\n BP: 149/94(107) {127/74(90) - 159/104(112)} mmHg\n RR: 27 (13 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,458 mL\n 4,792 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 1,408 mL\n 4,692 mL\n Blood products:\n Total out:\n 987 mL\n 4,412 mL\n Urine:\n 600 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 471 mL\n 380 mL\n Respiratory support\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Cushingoid\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Absent edema, Left lower\n extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.2 g/dL\n 505 K/uL\n 108 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 107 mEq/L\n 143 mEq/L\n 25.6 %\n 5.9 K/uL\n [image002.jpg]\n 08:09 PM\n 08:10 PM\n 03:07 AM\n WBC\n 6.0\n 5.9\n Hct\n 24.7\n 25.6\n Plt\n 566\n 505\n Cr\n 0.8\n 0.9\n Glucose\n 109\n 108\n Other labs: PT / PTT / INR:12.2/25.0/1.0, Ca++:8.6 mg/dL, Mg++:2.3\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n ANEMIA\n ======================\n Patient tolerating CVVH well. Electrolytes normal. Acid-base status\n normal.\n Hct at baseline. No evidence of bleeding. Not at transfusion threshold.\n Continue CVVH until methotrexate levels come down.\n ICU Care\n Nutrition: Oral\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments: VAP protocol not applicable\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2199-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490195, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n DIALYSIS CATHETER - START 07:00 PM\n - Emotional\n - vomited this AM\n - some discomfort in back of throat\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./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 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.2\nC (97.2\n HR: 88 (78 - 92) bpm\n BP: 159/91(107) {127/74(90) - 159/104(112)} mmHg\n RR: 19 (13 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,458 mL\n 3,897 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 1,408 mL\n 3,797 mL\n Blood products:\n Total out:\n 987 mL\n 3,745 mL\n Urine:\n 600 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 471 mL\n 152 mL\n Respiratory support\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n GEN: Middle-aged female, alert, not as tearful as yesterday\n HEENT: some alopecia right parietal area, a small mouth sore present,\n yellowish light plaque on tongue, didn\nt go away after brushing teeth\n CV: regular rhythm, 3/6 systolic murmur loudest at upper sternal border\n PULM: Patient is breathing comfortably. Clear to auscultation in\n posterior chest\n ABD: +BS, soft but full, mildly distended, nontender, midline\n abdominal scar\n EXT: no edema, extremities warm and well perfused, 2 + DP\n Neuro: CN II-XII grossly intact, sensation to light touch intact\n throughout. 5/5 strength in her upper and lower extremitites\n bilaterally.\n SKIN: Erythematous surrounding Right subclavian Dialysis catheter site\n and Left sided PICC line site\n Labs / Radiology\n 505 K/uL\n 8.2 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 107 mEq/L\n 143 mEq/L\n 25.6 %\n 5.9 K/uL\n [image002.jpg]\n 08:09 PM\n 08:10 PM\n 03:07 AM\n WBC\n 6.0\n 5.9\n Hct\n 24.7\n 25.6\n Plt\n 566\n 505\n Cr\n 0.8\n 0.9\n Glucose\n 109\n 108\n Other labs: PT / PTT / INR:12.2/25.0/1.0, Ca++:8.6 mg/dL, Mg++:2.3\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 39-year-old woman with type I diabetes, s/p 2 kidney transplants and a\n double kidney and pancreas transplant secondary to crescentic\n glomerulonephritis, now also with EBV-associated B-cell CNS lymphoma.\n # Acute renal failure s/p kidney transplant:\n Creatinine 2.9 on admission, but 0.9 today after hemodialysis and after\n having started CVVH. Possible that kidneys were further injured by\n methotrexate. Has some chronic renal insufficiency w the transplant\n kidneys. Now that she has been on HD, Cr level has been lowered to\n 0.8. Pancreas working fine; diabetes no longer an issue. CVVH until\n methotrexate level <0.1\n - continue on CellCept, per transplant recs; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6 and monitor urine for pH >7.5\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n - free calcium low\n stopped citrate w CVVH\n # EBV-Associated B-cell CNS Lymphoma: Just received cycle 2 of\n Methotrexate with leucovorin. how many cycles of methotrexate\n are planned.\n - continue leucovorin rescue, which was started on floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - monitor blood counts\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: emotional lability, and agitation. Thought to be secondary to\n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping\npt had refused SW consults in past in the ICU.\n - talk to Dr. about possibility of doing HD multiple times rather\n than CVVH b/c pt wanted to leave against medical advice this AM\n # Anemia: Hct stable at 25, near baseline. Likely secondary to recent\n chemo.\n - Trend Hct.\n - Continue ferrous sulfate.\n - Transfuse for Hct < 21.\n # Hypertension: BPs stable in 120s-150s.\n - continue home regimen of atenolol 100 mg po daily and amlodipine 5mg\n daily\n # Diabtes type 1 s/p pancreas transplant: Patient does not require\n insulin as an outpatient since her transplant.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: pneumoboots, subq heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2199-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490353, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n B cell CNS lymphoma, s/p treatment w/metotraxate, requiring CVVH for\n renal clearance. Last MTX level 0.34. W/goal of <0.1urine PH =>8.\n Bun/Cr wnl. Voiding adequate amnt. Denies pain.\n Action:\n Continue CVVH until goal MTX<0.1, urine Ph check w/each void. CVVH labs\n q6hr. Leucovorin rescue given ASDIR, bicarb gtt at 150cc/hr and po q6h.\n MTX levels . Renal and onc follows.\n Response:\n Ongoing\n Plan:\n Continue to monitor renal function and drug levels, f/u renal and onc\n recs.\n Neuro: alert oriented, follows commands, frequently sobbing and\ndoes\n not want to be on a machine anymore\n. Wants to be d/c so she can attend\n family function. SW involved to help w/cooping. Started on celexa and\n ativan PRN.\n Resp: on RA sata at high 90\ns. B/L LS clear. Denies resp distress.\n Cardio: B/P in 140-160\ns hr in 90\ns on metoprolol TID and amlodipine.\n Peripheral pulses present, no edema noted.\n GI: abd soft non tender, positive for BS. BM earlier yesterday. On\n Regular renal diet. Denies poor appetite, nausea. However at 0200am lg\n amnt of emesis\n mostly food and water in content. Zofran given w/good\n effect. .\n GU: voiding adequate amnt, using bed pan. PH =>8.0\n IV access: LT picc and RT HD cath, both are reddened at the site of the\n insertion. Team aware. Will follow for now.\n Social: patient is a FULL CODE> can be c/o when off CRRT.\n" }, { "category": "Physician ", "chartdate": "2199-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490430, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u lfts: 54-50-311\n - case management\n -lasix 10 daily if low uop\n -K was increasing (5.2) on a bag of 4.0 with decreasing bicarb; called\n renal; re-checked lytes at 0000. K was OK at 4.6 and HCO3 stable, so\n kept the same bags. No intervention done.\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1 grams/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 06:33 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: 36.6\nC (97.9\n HR: 88 (77 - 104) bpm\n BP: 175/102(128) {130/75(91) - 175/110(128)} mmHg\n RR: 22 (17 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,842 mL\n 1,920 mL\n PO:\n 2,400 mL\n TF:\n IVF:\n 8,442 mL\n 1,920 mL\n Blood products:\n Total out:\n 11,150 mL\n 2,833 mL\n Urine:\n 4,425 mL\n 910 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -308 mL\n -913 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GEN: Middle-aged female, alert, not as tearful as yesterday\n HEENT: some alopecia right parietal area, a small mouth sore present,\n yellowish light plaque on tongue, didn\nt go away after brushing teeth\n CV: regular rhythm, 3/6 systolic murmur loudest at upper sternal border\n PULM: Patient is breathing comfortably. Clear to auscultation in\n posterior chest\n ABD: +BS, soft but full, mildly distended, nontender, midline\n abdominal scar\n EXT: no edema, extremities warm and well perfused, 2 + DP\n Neuro: CN II-XII grossly intact, sensation to light touch intact\n throughout. 5/5 strength in her upper and lower extremitites\n bilaterally.\n SKIN: Erythematous surrounding Right subclavian Dialysis catheter site\n and Left sided PICC line site\n Labs / Radiology\n 524 K/uL\n 8.6 g/dL\n 132 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 11 mg/dL\n 106 mEq/L\n 134 mEq/L\n 26.4 %\n 8.7 K/uL\n [image002.jpg]\n 08:09 PM\n 08:10 PM\n 03:07 AM\n 09:02 AM\n 03:00 PM\n 09:02 PM\n 12:00 AM\n 03:01 AM\n WBC\n 6.0\n 5.9\n 8.7\n Hct\n 24.7\n 25.6\n 26.4\n Plt\n 566\n 505\n 524\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 109\n 108\n 95\n 134\n 114\n 115\n 132\n Other labs: PT / PTT / INR:11.6/24.7/1.0,\n ALT / AST:89/76,\n Alk Phos / T Bili:76/0.3,\n LDH:327 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 39-year-old woman with type I diabetes, s/p 2 kidney transplants and a\n double kidney and pancreas transplant secondary to crescentic\n glomerulonephritis, now also with EBV-associated B-cell CNS lymphoma.\n # Acute renal failure s/p kidney transplant:\n Creatinine 2.9 on admission, but 0.9 today after hemodialysis and after\n having started CVVH. Possible that kidneys were further injured by\n methotrexate. Has some chronic renal insufficiency w the transplant\n kidneys. Now that she has been on HD, Cr level has been lowered to\n 0.8. Pancreas working fine; diabetes no longer an issue. CVVH until\n methotrexate level <0.1\n - continue on CellCept, per transplant recs; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6 and monitor urine for pH >7.5\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n - free calcium low\n stopped citrate w CVVH\n # EBV-Associated B-cell CNS Lymphoma: Just received cycle 2 of\n Methotrexate with leucovorin. how many cycles of methotrexate\n are planned.\n - continue leucovorin rescue, which was started on floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - monitor blood counts\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: emotional lability, and agitation. Thought to be secondary to\n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult for coping\npt had refused SW consults in past in the ICU.\n - talk to Dr. about possibility of doing HD multiple times rather\n than CVVH b/c pt wanted to leave against medical advice this AM\n # Anemia: Hct stable at 25, near baseline. Likely secondary to recent\n chemo.\n - Trend Hct.\n - Continue ferrous sulfate.\n - Transfuse for Hct < 21.\n # Hypertension: BPs stable in 120s-150s.\n - continue home regimen of atenolol 100 mg po daily and amlodipine 5mg\n daily\n # Diabtes type 1 s/p pancreas transplant: Patient does not require\n insulin as an outpatient since her transplant.\n ICU Care\n Nutrition:\n Glycemic Control: None\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: pneumo boots, Heparin SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU pending completion of CVVH to decrease methotrexate\n level\n" }, { "category": "Nursing", "chartdate": "2199-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490275, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Continued on CRRT, alarms this morning for low access pressure and\n return pressure. Blood flow rate increased from 120 to 150 w/little\n effect, continued to alarm and blood flow rate increase to 250ml/min\n w/good effect. Citrate infusion stopped as well d/t hypocalcemia.\n Noting clots @ bottom of filter and small amount at top w/rescue\n flushes. Dialysis catheter site red, had small amt old blood drainage.\n Dressing changed and renal team assessed site @ bedside. PICC insertion\n site red as well, dressing changed today.\n Action:\n Blood flow rate increased to facilitate optimal pressures w/CRRT.\n Response:\n CRRT running without difficulty at present, small increase in amount of\n small clots @ filter after citrate stopped.\n Plan:\n CRRT as ordered. Monitor access sites, mark erythematic borders w/skin\n marker @ next dressing changes to better monitor the extent of\n erythema.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Emotionally labile, anxious, threatened to leave this morning. This\n afternoon continued to cry because she\nll needs CRRT overnight, wants\n to leave tomorrow for (which her sister says they can\n attend on Saturday). Patient reports frustration over being forced to\n remain in bed. Sister visited today, spoke w/social work as\n well. Requested that patient to be started on antidepressant to help\n w/mood stability. MTX level 1.7, cont w/leukovorin as prescribed, given\n IV as patient vomited this morning. Await 1500 MTX level.\n Action:\n Emotional support offered, patient appears to respond to 1:1 time spent\n @ bedside and speaking w/mother over the phone. Medicated x 1 w/.5mg PO\n ativan @ 1530 after renal MD recommended taking this to patient\n (patient refused this morning). Started on celexa today for apparent\n depression.\n Response:\n Ativan w/some effect, appeared to help patient to sleep. Needs\n continual emotional support and reminder that this is the course for\n her treatment of lymphoma.\n Plan:\n Cont to support emotionally. Social service and case management\n following.\n" }, { "category": "Nursing", "chartdate": "2199-08-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490421, "text": "The patient is a 39-year-old woman, with history of type I diabetes,\n glomerulonephritis, kidney transplants in and , and a double\n kidney and pancreas transplant in , who has EBV-associated B-cell\n CNS lymphoma diagnosed by brain biopsy in the setting of altered mental\n status. Due to chronic renal insufficiency and kidney transplant the\n patient requires CVVH/Dialysis while receiving methotrexate\n treatments.\n She was admitted to OMED on for methotrexate. Her last dose was\n between 1am-3am on . She had a full day of dialysis today and was\n transferred to the for continued clearance of methotrexate with\n CVVHD. She was also started on cellcept today per renal recs.\n The patient was admitted 2 weeks ago to the () for her first\n cycle of MTX and she tolerated this well. She is scheduled for\n q2weekly MTX treatments and so re-presents today.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n B cell CNS lymphoma, s/p treatment w/methotrexate ( cycles),\n requiring CVVH for renal clearance. Last MTX level 0.34 w/goal of\n <0.1urine PH =>8. Bun/Cr wnl. Voiding adequate amnt. Denies pain.\n Action:\n Continue CVVH until goal MTX<0.1, urine Ph check w/each void. CVVH labs\n q6hr. Leucovorin rescue given ASDIR, bicarb gtt at 150cc/hr and po q6h.\n MTX levels . Renal and onc follows. Patient off citrate relative\n hypocalcemia earlier yesterday. Frequent system flushes to avoid system\n clotting (q1-2hr)\n Response:\n Ongoing AM MTX level pending\n Plan:\n Continue to monitor renal function and drug levels, f/u renal and onc\n recs.\n Neuro: alert oriented, follows commands, frequently sobbing and\ndoes\n not want to be on a machine anymore\n. Wants to be d/c so she can attend\n family function. SW involved to help w/cooping. Started on celexa and\n ativan PRN.\n Resp: on RA sat at high 90\ns. B/L LS clear. Denies resp distress.\n Cardio: B/P in 140-160\ns hr in 90\ns on metoprolol TID and amlodipine.\n Peripheral pulses present, no edema noted.\n GI: abd soft non tender, positive for BS. BM earlier yesterday. On\n regular renal diet. Denies poor appetite, nausea. However at 0200am lg\n amnt of emesis\n mostly food and water in content. Zofran given w/good\n effect. .\n GU: voiding adequate amnt, using bed pan. Urine PH =>8.0\n IV access: LT picc and RT HD cath, both are reddened at the site of the\n insertion. Team aware. Will follow for now.\n Social: patient is a FULL CODE> can be c/o when off CRRT.\n" }, { "category": "Physician ", "chartdate": "2199-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490629, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u lfts: 54-50-311\n - case management\n -lasix 10 daily if low uop\n -K was increasing (5.2) on a bag of 4.0 with decreasing bicarb; called\n renal; re-checked lytes at 0000. K was OK at 4.6 and HCO3 stable, so\n kept the same bags. No intervention done.\n Allergies:\n Ampicillin\n Hives;\n Penicillins\n Unknown;\n Morphine Hcl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1 grams/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 06:33 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: 36.6\nC (97.9\n HR: 88 (77 - 104) bpm\n BP: 175/102(128) {130/75(91) - 175/110(128)} mmHg\n RR: 22 (17 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,842 mL\n 1,920 mL\n PO:\n 2,400 mL\n TF:\n IVF:\n 8,442 mL\n 1,920 mL\n Blood products:\n Total out:\n 11,150 mL\n 2,833 mL\n Urine:\n 4,425 mL\n 910 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -308 mL\n -913 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GEN: Middle-aged female, alert, not as tearful as yesterday\n HEENT: some alopecia right parietal area, a small mouth sore present,\n yellowish light plaque on tongue, didn\nt go away after brushing teeth\n CV: regular rhythm, 3/6 systolic murmur loudest at upper sternal border\n PULM: Patient is breathing comfortably. Clear to auscultation in\n posterior chest\n ABD: +BS, soft but full, mildly distended, nontender, midline\n abdominal scar\n EXT: no edema, extremities warm and well perfused, 2 + DP\n Neuro: CN II-XII grossly intact, sensation to light touch intact\n throughout. 5/5 strength in her upper and lower extremitites\n bilaterally.\n SKIN: Erythematous surrounding Right subclavian Dialysis catheter site\n and Left sided PICC line site\n Labs / Radiology\n 524 K/uL\n 8.6 g/dL\n 132 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 11 mg/dL\n 106 mEq/L\n 134 mEq/L\n 26.4 %\n 8.7 K/uL\n [image002.jpg]\n 08:09 PM\n 08:10 PM\n 03:07 AM\n 09:02 AM\n 03:00 PM\n 09:02 PM\n 12:00 AM\n 03:01 AM\n WBC\n 6.0\n 5.9\n 8.7\n Hct\n 24.7\n 25.6\n 26.4\n Plt\n 566\n 505\n 524\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 109\n 108\n 95\n 134\n 114\n 115\n 132\n Other labs: PT / PTT / INR:11.6/24.7/1.0,\n ALT / AST:89/76,\n Alk Phos / T Bili:76/0.3,\n LDH:327 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 39-year-old woman with type I diabetes, s/p 2 kidney transplants and a\n double kidney and pancreas transplant secondary to crescentic\n glomerulonephritis, now also with EBV-associated B-cell CNS lymphoma.\n # Acute renal failure s/p kidney transplant:\n Creatinine 2.9 on admission, but 0.9 today after hemodialysis and after\n having started CVVH. Possible that kidneys were further injured by\n methotrexate. Has some chronic renal insufficiency w the transplant\n kidneys. Now that she has been on HD, Cr level has been lowered to\n 0.8. Pancreas working fine; diabetes no longer an issue. CVVH until\n methotrexate level <0.1\n - continue on CellCept, per transplant recs; continue prednisone 4mg\n daily\n - cont sodium bicarb 1300 PO Q6 and monitor urine for pH >7.5\n - follow up renal recommendations; renal transplant team is following\n and managing CVVH.\n - free calcium low\n stopped citrate w CVVH\n # EBV-Associated B-cell CNS Lymphoma: Just received cycle 2 of\n Methotrexate with leucovorin. how many cycles of methotrexate\n are planned.\n - continue leucovorin rescue, which was started on floor per Dr. \n - alkalinizing urine with bicarb (follow urine PH) and initiating CVVH\n for MTX clearance\n - F/u MTX levels as directed by onc.\n - monitor blood counts\n - antiemetics with zofran prn\n - f/u Onc recs\n # Psych: emotional lability, and agitation. Thought to be secondary to\n lymphoma.\n - Continued reassurance.\n - Ativan prn for anxiety and insomnia.\n - SW consult spoke with family, appears emotional lability has been\n long standing issue\n - started citalopram 10mg daily\n # Anemia: Hct stable at 26.4, near baseline. Likely secondary to\n recent chemo.\n - Trend Hct.\n - Continue ferrous sulfate.\n - Transfuse for Hct < 21.\n # Hypertension: BPs stable in 120s-150s.\n - continue home regimen of atenolol 100 mg po daily and amlodipine 5mg\n daily\n # Diabtes type 1 s/p pancreas transplant: Patient does not require\n insulin as an outpatient since her transplant.\n ICU Care\n Nutrition:\n Glycemic Control: None\n Lines:\n PICC Line - 07:00 PM\n Dialysis Catheter - 07:00 PM\n Prophylaxis:\n DVT: pneumo boots, Heparin SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition: Hopeful d/c home today pending methotrexate level\n" } ]

[ { "category": "Physician ", "chartdate": "2163-09-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483775, "text": "Chief Complaint: Respiratory failure\n 24 Hour Events:\n EKG - At 05:36 PM\n NON-INVASIVE VENTILATION - START 06:08 PM\n - admitted yesterday afternoon\n - attempted Bipap but pt only tolerated for a few hours and then slept\n with 3 L NC instead\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 87 (79 - 113) bpm\n BP: 88/40(53) {88/40(53) - 141/79(93)} mmHg\n RR: 15 (15 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 545 mL\n PO:\n 545 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 780 mL\n 550 mL\n Urine:\n 780 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -235 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (492 - 492) mL\n PS : 10 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.43/62/69/39/13\n Ve: 11.2 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 659 K/uL\n 9.4 g/dL\n 148 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 5.3 mEq/L\n 11 mg/dL\n 90 mEq/L\n 133 mEq/L\n 32.9 %\n 21.0 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n WBC\n 20.8\n 21.0\n Hct\n 31.9\n 32.9\n Plt\n 614\n 659\n Cr\n 0.5\n 0.5\n TCO2\n 43\n Glucose\n 93\n 148\n Other labs: Ca++:9.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap)\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture\n - solumedrol 60mg IV bid\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production\n - consider retrying BIPAP if pt agreeable\n - continue Mucomyst, Mucinex, Advair\n .\n # Leukocytosis:\n - add on diff\n - check UA/Ucx and blood cx for further evaluation\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP. Now\n improved. Reck ABG if worsening somnolence\n - BiPAP\n - ABGs\n .\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on Wednesday to exchange stent and debridement\n - NPO past M/N\n .\n # Squamous cell CA: Rad onc Dr \n - f/u Dr. as outpatient\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO after MN for OR\n # PPX: omeprazole (home), heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient). If pt requiring aggressive life\n saving measures x 3 days, would prefer to withdraw care.\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483747, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Events: Pt refused BiPap overnight. Tolerating 3 L NC 02 with good\n Sats\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2163-09-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483752, "text": "Chief Complaint: Respiratory failure\n 24 Hour Events:\n EKG - At 05:36 PM\n NON-INVASIVE VENTILATION - START 06:08 PM\n - admitted yesterday afternoon\n - attempted Bipap but pt only tolerated for a few hours and then slept\n with 3 L NC instead\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 87 (79 - 113) bpm\n BP: 88/40(53) {88/40(53) - 141/79(93)} mmHg\n RR: 15 (15 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 545 mL\n PO:\n 545 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 780 mL\n 550 mL\n Urine:\n 780 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -235 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (492 - 492) mL\n PS : 10 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.43/62/69/39/13\n Ve: 11.2 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 659 K/uL\n 9.4 g/dL\n 148 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 5.3 mEq/L\n 11 mg/dL\n 90 mEq/L\n 133 mEq/L\n 32.9 %\n 21.0 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n WBC\n 20.8\n 21.0\n Hct\n 31.9\n 32.9\n Plt\n 614\n 659\n Cr\n 0.5\n 0.5\n TCO2\n 43\n Glucose\n 93\n 148\n Other labs: Ca++:9.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 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": "2163-09-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483755, "text": "Chief Complaint: Respiratory failure\n 24 Hour Events:\n EKG - At 05:36 PM\n NON-INVASIVE VENTILATION - START 06:08 PM\n - admitted yesterday afternoon\n - attempted Bipap but pt only tolerated for a few hours and then slept\n with 3 L NC instead\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 87 (79 - 113) bpm\n BP: 88/40(53) {88/40(53) - 141/79(93)} mmHg\n RR: 15 (15 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 545 mL\n PO:\n 545 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 780 mL\n 550 mL\n Urine:\n 780 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -235 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (492 - 492) mL\n PS : 10 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.43/62/69/39/13\n Ve: 11.2 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 659 K/uL\n 9.4 g/dL\n 148 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 5.3 mEq/L\n 11 mg/dL\n 90 mEq/L\n 133 mEq/L\n 32.9 %\n 21.0 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n WBC\n 20.8\n 21.0\n Hct\n 31.9\n 32.9\n Plt\n 614\n 659\n Cr\n 0.5\n 0.5\n TCO2\n 43\n Glucose\n 93\n 148\n Other labs: Ca++:9.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap)\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture\n - IV solumedrol\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production\n - BiPAP overnight\n - continue Mucomyst, Mucinex, Advair\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP.\n - BiPAP\n - ABGs\n .\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on Wednesday to exchange stent and debridement\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO after MN for OR\n # PPX: omeprazole (home), heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient)\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483862, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Events: Pt refused BiPap overnight. Tolerating 3 L NC 02 with good\n Sats\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Bs clear upper. Diminished at the bases. Coughing and raising thick tan\n secretions.\n Action:\n Plan for or tomorrow for stent removal and placement of new stent.\n Response:\n Stable resp status.\n Plan:\n Npo after mn for or in am.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Bs clear diminsished at the bases. Occasional wheezes. Resp mid 20\n sating high 80\ns to low 90\ns on 3l nc.\n Action:\n Cont on steroids that are being weaned, cont albuterol, Atrovent, and\n acetylcysteine nebs. Cont on advir and guaifenesin dextromethorphan.\n Cont on azithromycin 250mg q 24 . Goal sat is 88-93%.\n Response:\n Stable on 3l nc.\n Plan:\n Cont nebs, antibiodics and steroids as ordered\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483782, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Events: Pt refused BiPap overnight. Tolerating 3 L NC 02 with good\n Sats\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Bs clear upper. Diminished at the bases. Coughing and raising thick tan\n secretions.\n Action:\n Plan for or tomorrow for stent removal and placement of new stent.\n Response:\n Stable resp status.\n Plan:\n Npo after mn for or in am.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Bs clear diminsished at the bases. Occasional wheezes. Resp mid 20\n sating high 80\ns to low 90\ns on 3l nc.\n Action:\n Cont on steroids that are being weaned, cont albuterol, Atrovent, and\n acetylcysteine nebs. Cont on advir and guaifenesin dextromethorphan.\n Cont on azithromycin 250mg q 24 . Goal sat is 88-93%.\n Response:\n Stable on 3l nc.\n Plan:\n Cont nebs, antibiodics and steroids as ordered\n" }, { "category": "Nursing", "chartdate": "2163-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483667, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n .\n Currently, the patient feels slightly better than prior days. Has had\n increased sputum production over several weeks but no change in color\n (greyish).\n Denies fever, chills, night sweats, rhinorrhea, congestion, chest pain,\n abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,\n melena, hematochezia, dysuria, hematuria\n" }, { "category": "Nursing", "chartdate": "2163-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483674, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n .\n Currently, the patient feels slightly better than prior days. Has had\n increased sputum production over several weeks but no change in color\n (greyish).\n Denies fever, chills, night sweats, rhinorrhea, congestion, chest pain,\n abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,\n melena, hematochezia, dysuria, hematuria\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Pt adm from the Bronch suite. He was A&O x3, following all commands ,\n He reports no c/o SOB but some increased secretions. His O2 sats\n Action:\n He was placed on 3l NP O2, to start on steroids, given inhalers and\n will cont on his usual meds\n Response:\n Pt with O2 sats of 85-95%\n Plan:\n To go to OR on Wed for replacement of stent , Try CpAP this eve, treat\n for COPD flare\n Social:pt\ns daughter aware of pt adm, numbers in room\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483865, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Events: Pt refused BiPap overnight. Tolerating 3 L NC 02 with good\n Sats\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Bs clear upper. Diminished at the bases. Coughing and raising thick tan\n secretions.\n Action:\n Plan for or tomorrow for stent removal and placement of new stent.\n Response:\n Stable resp status.\n Plan:\n Npo after mn for or in am.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Bs clear diminsished at the bases. Occasional wheezes. Resp mid 20\n sating high 80\ns to low 90\ns on 3l nc.\n Action:\n Cont on steroids that are being weaned, cont albuterol, Atrovent, and\n acetylcysteine nebs. Cont on advir and guaifenesin dextromethorphan.\n Cont on azithromycin 250mg q 24 . Goal sat is 88-93%.\n Response:\n Stable on 3l nc.\n Plan:\n Cont nebs, antibiodics and steroids as ordered\n Leukocytosis\n Assessment:\n Wbc 21 this am in setting of high dose steroids.\n Action:\n Bc x2, urine for u/a c and s sent. Sputum for c and s and gm stain\n sent. Cont on azithromycin. Repeat wbc drawn.\n Response:\n Repeat wbc 18.9,\n Plan:\n Cont to monitor results of cult.\n Electrolyte & fluid disorder, other\n Assessment:\n K this am 5.3.\n Action:\n K repeated.\n Response:\n K 5.8. Dr made aware. Ekg done. Without peaked t\ns per dr .\n Reat k drawn.\n Plan:\n K pending.\n Social- no calls to this nurse from family. Daghters did call and\n talked to patient. Npo after mn for or at 11am.\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483681, "text": "Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483941, "text": "Pt arrived to MICU from IP s/p bronch complicated by increased SOB,\n hypotensive and decreased mental status with meds post procedure. Plan\n is to go to the OR at 11am for removal of his y-stent and\n replacement. Pmhx significant for COPD, CAD, squamous cell lung CA\n lobectomy with reoccurence, had cyberknife therapy. Stent placement\n with cardiac arrest, OSA with CPAP-concompliant; smoker. Elevated\n WBC 21- pan cx , begun on methylprednisone.\n Electrolyte & fluid disorder, other\n Assessment:\n EKG performed for elevated K of 5.8, no peaked t\ns noted.\n Denies increased thirst, CP. NA decreased from 131 to 128\n Action:\n NS at 100cc/hr begun. Enc intake of fluids other than water; NPO after\n 12mn for OR. Am labs drawn\n Response:\n NPO.\n Plan:\n Cont to monitor lytes. Anticipate po\ns after OR.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Received pt OOB in chair; toleratiing well; cough, NP. Tolerated\n 100% of meal eaten over extended length of time d/t resp status\n Action:\n Assisted back to bed, mod severe DOE. Desaturates quickly to low 80\n off oxygen. Maintined on 3 L nc overnight.\n Response:\n Slept fairly well. Cont to desaturate quickly with decreased o2\n supply. Severe DOE\n Plan:\n NPO. Or today for y-stent removal and replacement\nF/U with team for\n elevated WBC to 25 from 18---?r/t s/p bronch.\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483913, "text": "Pt arrived to MICU from IP s/p bronch complicated by increased SOB,\n hypotensive and decreased mental status with meds post procedure. Plan\n is to go to the OR at 11am for removal of his y-stent and\n replacement. Pmhx significant for COPD, CAD, squamous cell lung CA\n lobectomy with reoccurence, had cyberknife therapy. Stent placement\n with cardiac arrest, OSA with CPAP-concompliant; smoker. Elevated\n WBC 21- pan cx , begun on methylprednisone.\n Electrolyte & fluid disorder, other\n Assessment:\n EKG performed for elevated K of 5.8, no peaked t\ns noted.\n Denies increased thirst, CP. NA decreased from 131 to 128\n Action:\n NS at 100cc/hr begun. Enc intake of fluids other than water; NPO after\n 12mn for OR. Am labs drawn\n Response:\n NPO.\n Plan:\n Cont to monitor lytes. Anticipate po\ns after OR.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Received pt OOB in chair; toleratiing well; cough, NP. Tolerated\n 100% of meal eaten over extended length of time d/t resp status\n Action:\n Assisted back to bed, mod severe DOE. Desaturates quickly to low 80\n off oxygen. Maintined on 3 L nc overnight.\n Response:\n Slept fairly well. Cont to desaturate quickly with decreased o2\n supply. Severe DOE\n Plan:\n NPO. Or today for y-stent removal and replacement.\n" }, { "category": "Physician ", "chartdate": "2163-09-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 483650, "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 67M COPD, TBM, y-stent in place and longstanding problem with ,\n congestion, dyspnea. His respiratory status has been worsening on a\n subacute basis. Presented today because of worsening SOB and somnolence\n for bronch.\n During bronch, secretions seen throughout right. Post-bronch\n complicated by somnolence, hypoxemia and hypoventialtion. He was put on\n higher O2 and improved.\n Plan is for stent replacement in 2 days in OR.\n 24 Hour Events:\n History obtained from housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n COPD\n TBM - s/p Y-stent\n RUL resection NSCLCa.\n recurrent NSCLCa. - s/p CK, recent concerning PET/CT for progressive\n disease in RLL and LNs\n active smoker\n OSA - untreated\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 05:49 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 105 (103 - 105) bpm\n BP: 141/59(77) {141/59(77) - 141/59(77)} mmHg\n RR: 28 (22 - 28) insp/min\n SpO2: 87%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 87% 3L NC\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: some Wheezes, significant rhonchi\n Abd benign\n Neurologic: Attentive, Follows simple commands, Responds to questions\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Resp distress post bronch - status has been worsening over past number\n of weeks. Has a number of possible explanations including COPD,\n infection, progressive TBM, stent obstruction and cancer progression.\n Will treat COPD flare with steroids, bronchodilators, antibiotics.\n Check CXR. BIPAP overnight. Stent replacement per IP.\n Lung cancer - does not appear that there are treatment options.\n Continue supportive care.\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2163-09-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483982, "text": "ICU RESIDENT PROGRESS NOTE\n 24 Hour Events:\n \n Decreased steroids to 60 IV bid\n UA negative\n Worsening hyponatremia. LOS negative. Gave trial of NS IVFs. Repeat\n lytes in AM improved with NS.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:33 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 07:33 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: 36.2\nC (97.2\n HR: 92 (75 - 102) bpm\n BP: 134/77(92) {91/31(45) - 139/77(92)} mmHg\n RR: 19 (11 - 34) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,120 mL\n 638 mL\n PO:\n 1,120 mL\n TF:\n IVF:\n 638 mL\n Blood products:\n Total out:\n 1,525 mL\n 1,100 mL\n Urine:\n 1,525 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -405 mL\n -462 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: ///38/\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 660 K/uL\n 9.2 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 5.1 mEq/L\n 15 mg/dL\n 91 mEq/L\n 134 mEq/L\n 30.9 %\n 25.1 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n 03:29 PM\n 05:44 PM\n 03:25 AM\n WBC\n 20.8\n 21.0\n 18.9\n 25.1\n Hct\n 31.9\n 32.9\n 29.5\n 30.9\n Plt\n 60\n Cr\n 0.5\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 43\n Glucose\n 93\n 148\n 88\n 121\n Other labs: Differential-Neuts:97.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n 8:02 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife for\n recurrence, s/p flex bronchoscopy, now admitted to MICU for COPD\n exacerbation and closer respiratory monitoring.\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture, no growth to date\n - solumedrol 60 IV daily\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production, on\n day \n - continue Mucomyst, Mucinex, Advair\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on for exchange stent and debridement\n - NPO for procedure\n .\n # Leukocytosis: likely secondary to IV steriods, but could have\n possible infection.\n - monitor WBC\n - f/u cx\n - CIS\n - if starts to have diarrhea will check c. diff, since been on abx\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP. Now\n improved.\n - Recheck ABG if worsening somnolence\n .\n # Squamous cell CA: Rad onc Dr \n - f/u Dr. as outpatient\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO after MN for OR\n # PPX: omeprazole (home), heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient). If pt requiring aggressive life\n saving measures x 3 days, would prefer to withdraw care.\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: NPO for procedure today\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n 20 Gauge - 03:38 AM\n Prophylaxis:\n DVT: hep sq\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: procedure today, then if stable transfer to floor\n" }, { "category": "Physician ", "chartdate": "2163-09-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483983, "text": "ICU RESIDENT PROGRESS NOTE\n 24 Hour Events:\n \n Decreased steroids to 60 IV bid\n UA negative\n Worsening hyponatremia. LOS negative. Gave trial of NS IVFs. Repeat\n lytes in AM improved with NS.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:33 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 07:33 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: 36.2\nC (97.2\n HR: 92 (75 - 102) bpm\n BP: 134/77(92) {91/31(45) - 139/77(92)} mmHg\n RR: 19 (11 - 34) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,120 mL\n 638 mL\n PO:\n 1,120 mL\n TF:\n IVF:\n 638 mL\n Blood products:\n Total out:\n 1,525 mL\n 1,100 mL\n Urine:\n 1,525 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -405 mL\n -462 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: ///38/\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 660 K/uL\n 9.2 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 5.1 mEq/L\n 15 mg/dL\n 91 mEq/L\n 134 mEq/L\n 30.9 %\n 25.1 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n 03:29 PM\n 05:44 PM\n 03:25 AM\n WBC\n 20.8\n 21.0\n 18.9\n 25.1\n Hct\n 31.9\n 32.9\n 29.5\n 30.9\n Plt\n 60\n Cr\n 0.5\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 43\n Glucose\n 93\n 148\n 88\n 121\n Other labs: Differential-Neuts:97.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n 8:02 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife for\n recurrence, s/p flex bronchoscopy, now admitted to MICU for COPD\n exacerbation and closer respiratory monitoring.\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture, no growth to date\n - solumedrol 60 IV daily\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production, on\n day \n - continue Mucomyst, Mucinex, Advair\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on for exchange stent and debridement\n - NPO for procedure\n .\n # Leukocytosis: likely secondary to IV steriods, but could have\n possible infection.\n - monitor WBC\n - f/u cx\n - CIS\n - if starts to have diarrhea will check c. diff, since been on abx\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP. Now\n improved.\n - Recheck ABG if worsening somnolence\n .\n # Squamous cell CA: Rad onc Dr \n - f/u Dr. as outpatient\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO for OR\n # PPX: omeprazole (home), heparin SQ (hold today for OR), bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient). If pt requiring aggressive life\n saving measures x 3 days, would prefer to withdraw care.\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: NPO for procedure today, then advance diet\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n 20 Gauge - 03:38 AM\n Prophylaxis:\n DVT: hep sq (hold for procedure)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: procedure today, then if stable transfer to floor\n" }, { "category": "Physician ", "chartdate": "2163-09-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 483984, "text": "Chief Complaint: Hypoxia, hypercarbia with TBM and stent obstruction.\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 Stable night awaiting OR for stent replacement today.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:33 AM\n Other medications:\n azithromycin, albuterol nebs, mucomyst, advair, HCTZ, synthroid, asa,\n simvastatin, quinipril, omeprazole, naproxen, dextromethorphan,\n methylprednisolone.\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 11:07 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: 35.6\nC (96\n HR: 93 (73 - 98) bpm\n BP: 123/56(70) {91/31(45) - 139/77(92)} mmHg\n RR: 17 (11 - 34) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,120 mL\n 972 mL\n PO:\n 1,120 mL\n TF:\n IVF:\n 972 mL\n Blood products:\n Total out:\n 1,525 mL\n 2,250 mL\n Urine:\n 1,525 mL\n 2,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -405 mL\n -1,278 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 3L\n SpO2: 99%\n ABG: ///38/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), difficult to\n assess heart sounds clearly due to loud rhonchi\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal\n Labs / Radiology\n 9.2 g/dL\n 660 K/uL\n 121 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 5.1 mEq/L\n 15 mg/dL\n 91 mEq/L\n 134 mEq/L\n 30.9 %\n 25.1 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n 03:29 PM\n 05:44 PM\n 03:25 AM\n WBC\n 20.8\n 21.0\n 18.9\n 25.1\n Hct\n 31.9\n 32.9\n 29.5\n 30.9\n Plt\n 60\n Cr\n 0.5\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 43\n Glucose\n 93\n 148\n 88\n 121\n Other labs: Differential-Neuts:97.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Microbiology: sputum multiple organisms c/w oral flora\n Assessment and Plan\n LEUKOCYTOSIS:\n cultures are negative to date, on solumedrol. Continue to monitor.\n ELECTROLYTE & FLUID DISORDER, OTHER\n Hyperkalemia: trendign down. continue to monitor.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION:\n wean steroids to 30 of columedrol x1 more day. Contineu azithro and\n nebs.\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA)\n For Y stent exchange and debridement in OR today.\n ICU Care\n Nutrition: NPO for procedure.\n Glycemic Control:\n Lines:\n 20 Gauge - 03:38 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2163-09-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 484015, "text": "ICU RESIDENT PROGRESS NOTE\n 24 Hour Events:\n \n Decreased steroids to 60 IV bid\n UA negative\n Worsening hyponatremia. LOS negative. Gave trial of NS IVFs. Repeat\n lytes in AM improved with NS.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:33 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 07:33 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: 36.2\nC (97.2\n HR: 92 (75 - 102) bpm\n BP: 134/77(92) {91/31(45) - 139/77(92)} mmHg\n RR: 19 (11 - 34) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,120 mL\n 638 mL\n PO:\n 1,120 mL\n TF:\n IVF:\n 638 mL\n Blood products:\n Total out:\n 1,525 mL\n 1,100 mL\n Urine:\n 1,525 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -405 mL\n -462 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: ///38/\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 660 K/uL\n 9.2 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 5.1 mEq/L\n 15 mg/dL\n 91 mEq/L\n 134 mEq/L\n 30.9 %\n 25.1 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n 03:29 PM\n 05:44 PM\n 03:25 AM\n WBC\n 20.8\n 21.0\n 18.9\n 25.1\n Hct\n 31.9\n 32.9\n 29.5\n 30.9\n Plt\n 60\n Cr\n 0.5\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 43\n Glucose\n 93\n 148\n 88\n 121\n Other labs: Differential-Neuts:97.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n 8:02 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife for\n recurrence, s/p flex bronchoscopy, now admitted to MICU for COPD\n exacerbation and closer respiratory monitoring.\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture, no growth to date\n - solumedrol 60 IV daily\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production, on\n day \n - continue Mucomyst, Mucinex, Advair\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on for exchange stent and debridement\n - NPO for procedure\n .\n # Leukocytosis: likely secondary to IV steriods, but could have\n possible infection.\n - monitor WBC\n - f/u cx\n - CIS\n - if starts to have diarrhea will check c. diff, since been on abx\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP. Now\n improved.\n - Recheck ABG if worsening somnolence\n .\n # Squamous cell CA: Rad onc Dr \n - f/u Dr. as outpatient\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO for OR\n # PPX: omeprazole (home), heparin SQ (hold today for OR), bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient). If pt requiring aggressive life\n saving measures x 3 days, would prefer to withdraw care.\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: NPO for procedure today, then advance diet\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n 20 Gauge - 03:38 AM\n Prophylaxis:\n DVT: hep sq (hold for procedure)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: procedure today, then if stable transfer to floor\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:25 ------\n" }, { "category": "ECG", "chartdate": "2163-09-13 00:00:00.000", "description": "Report", "row_id": 214445, "text": "Sinus rhythm. The tracing is marred by baseline artifact. Compared to the\nprevious tracing of there is no diagostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2163-09-12 00:00:00.000", "description": "Report", "row_id": 214446, "text": "Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of no definite change.\n\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483990, "text": "Preop note.\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Patient coughing and raising thick grayish tan secretions this am. Sats\n high 80\ns to low 90\ns on 3l nc. Resp high teens to low 20\n Action:\n Preop for stent removal and replacement.\n Response:\n Preop for or. Daughter in and took patient\ns wallet, 2 rings and\n watch.\n Plan:\n Ready for or. Anesthesia transported patient to or at 1130.\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483996, "text": "67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Returned from the or at 1230. Ip was unable to replace stent. Lots of\n purulent secretions in old stent. Old stent was removed and bronch\n done to clear secretions. Arrived in unit coughing without raising.\n Sats mid 90\ns on 3l facemask.\n Action:\n Lidocaine neb ordered and given as well as 30mg iv codeine phosphate.\n Response:\n On 3l fm sats low 90\ns. Intermittent coughing cont.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484064, "text": "67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Returned from the or at 1230. Ip was unable to replace stent. Lots of\n purulent secretions in old stent. Old stent was removed and bronch\n done to clear secretions. Arrived in unit coughing without raising.\n Sats mid 90\ns on 3l facemask.\n Action:\n Lidocaine neb ordered and given as well as 30mg iv codeine phosphate.\n Response:\n On 3l fm sats low 90\ns. Back to pre OR resp status. Not as many\n secretions though.\n Plan:\n Plan is for pt to evaluate to see how patient does walking to see if he\n is safe for home. ? d/c home and return per ip for new stent.\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483977, "text": "Preop note.\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Patient coughing and raising thick grayish tan secretions this am. Sats\n high 80\ns to low 90\ns on 3l nc. Resp high teens to low 20\n Action:\n Preop for stent removal and replacement.\n Response:\n Preop for or. Daughter in and took patient\ns wallet, 2 rings and watch.\n Plan:\n Ready for or.\n" }, { "category": "Physician ", "chartdate": "2163-09-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483964, "text": "TITLE:\n Chief Complaint: \n Decreased steroids to 60 IV bid\n UA negative\n Worsening hyponatremia. LOS negative. Gave trial of NS IVFs. Repeat\n lytes in AM improved with NS.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:33 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 07:33 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: 36.2\nC (97.2\n HR: 92 (75 - 102) bpm\n BP: 134/77(92) {91/31(45) - 139/77(92)} mmHg\n RR: 19 (11 - 34) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,120 mL\n 638 mL\n PO:\n 1,120 mL\n TF:\n IVF:\n 638 mL\n Blood products:\n Total out:\n 1,525 mL\n 1,100 mL\n Urine:\n 1,525 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -405 mL\n -462 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: ///38/\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 660 K/uL\n 9.2 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 38 mEq/L\n 5.1 mEq/L\n 15 mg/dL\n 91 mEq/L\n 134 mEq/L\n 30.9 %\n 25.1 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n 03:29 PM\n 05:44 PM\n 03:25 AM\n WBC\n 20.8\n 21.0\n 18.9\n 25.1\n Hct\n 31.9\n 32.9\n 29.5\n 30.9\n Plt\n 60\n Cr\n 0.5\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 43\n Glucose\n 93\n 148\n 88\n 121\n Other labs: Differential-Neuts:97.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n 8:02 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Assessment and Plan\n LEUKOCYTOSIS\n ELECTROLYTE & FLUID DISORDER, OTHER\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA)\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap)\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture, no growth to date\n - solumedrol 60mg IV bid\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production, on\n day \n - consider retrying BIPAP if pt agreeable\n - continue Mucomyst, Mucinex, Advair\n .\n # Leukocytosis: likely secondary to IV steriods, but could have\n possible infection.\n - monitor WBC\n - f/u cx\n - if starts to have diarrhea will check c. diff, since been on abx\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP. Now\n improved. Reck ABG if worsening somnolence\n - BiPAP, pt refusing\n - ABGs\n .\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on for exchange stent and debridement\n - NPO for procedure\n .\n # Squamous cell CA: Rad onc Dr \n - f/u Dr. as outpatient\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO after MN for OR\n # PPX: omeprazole (home), heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient). If pt requiring aggressive life\n saving measures x 3 days, would prefer to withdraw care.\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: NPO for procedure today\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n 20 Gauge - 03:38 AM\n Prophylaxis:\n DVT: hep sq\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: procedure today, then if stable transfer to floor\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 484063, "text": "67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Returned from the or at 1230. Ip was unable to replace stent. Lots of\n purulent secretions in old stent. Old stent was removed and bronch\n done to clear secretions. Arrived in unit coughing without raising.\n Sats mid 90\ns on 3l facemask.\n Action:\n Lidocaine neb ordered and given as well as 30mg iv codeine phosphate.\n Response:\n On 3l fm sats low 90\ns. Back to pre OR resp status. Not as many\n secretions though.\n Plan:\n Plan is for pt to evaluate to see how patient does walking to see if he\n is safe for home. ? d/c home and return per ip for new stent.\n Review of systems-\n Neuro- alert and oriented x3. cooperative with care.\n Resp- on 3l nc with sats high 80\ns to low 90\ns. resp mid teens to low\n 20\ns. desats with activity. Recovers with rest. Coughs and is able to\n raise at times thick grey tan green sputum. rhonchorous upper. BS\n diminished at the bases. Unable to wear bipap at night.\n Cardiac- hr 70-90\ns nsr. Sbp 90-120\n Gi- on heart healthy diet. Tolerates this well. Last moved bowels .\n Gu- voids in urinal clear yellow urine.\n Access- #22 in right forearm from .\n Social- has 2 daughters and .\n" }, { "category": "Physician ", "chartdate": "2163-09-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 483641, "text": "Chief Complaint: PCP: , \n Followed by Dr. at and Dr. at .\n REASON FOR ICU ADMISSION: Noninvasive ventilation\n CC: Respiratory distress.\n HPI:\n Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n .\n Currently, the patient feels slightly better than prior days. Has had\n increased sputum production over several weeks but no change in color\n (greyish).\n Denies fever, chills, night sweats, rhinorrhea, congestion, chest pain,\n abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,\n melena, hematochezia, dysuria, hematuria.\n Patient admitted from: Chest Disease Clinic\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Squamous cell CA sp RUL lobectomy (), recurrence s/p Cyberknife CAD\n s/p cardiac arrest and stent placement\n COPD/emphysema\n Tracheobronchomalacia s/p Y stent\n OSA (on nocturnal CPAP)\n HTN\n Hypothyroidism\n Gout\n Hypercholesterolemia\n Brother had TB, CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Single, retired from the telephone company. Drinks 3-4\n beers/night. Was a 100+ ppy smoker, now smokes ppd. Has no known\n exposure to asbestos.\n Review of systems:\n Flowsheet Data as of 05:27 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 105 (103 - 105) bpm\n BP: 141/59(77) {141/59(77) - 141/59(77)} mmHg\n RR: 28 (22 - 28) insp/min\n SpO2: 86%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 86%\n Physical Examination\n Vitals - T: 96.6 BP: 141/79 HR: 109 RR: 22 02 sat: 86% 3 L NC\n GENERAL: appears older than stated age, slightly tachpneic\n HEENT: anicteric, EOMI, cushingoid features, OP - no exudate, no\n erythema, no cervical LAD\n CARDIAC: sinus tach, no m/r/g\n LUNG: wheezes scattered, prominent in RUL, decreased BS throughout lung\n fields\n ABDOMEN: NDNT, soft, NABs\n EXT: no c/c/e\n NEURO: II-XII grossly intact\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: pH 7.32 pCO2 80 pO2 59 HCO3 43 BaseXS 10\n Imaging: CXR: pending\n Flexible Bronchoscopy \n Upper airways looked normal. Distal to the vocal\n cord, there was extensive amount of thick mucus plugging and\n secretions within the stent lumen which was particularly\n aspirated. The proximal end showed mild to moderate amount\n of granulation tissue, however, there was no significant\n luminal compromise. In the distal and at the right main stem\n bronchus, there was near-complete occlusion of that end due\n to combination of granulation tissue and underlying residual\n malacia. We could not pass the scope beyond that element but\n the distal airways looked patent during a saline flush. On\n the left side, there was mild granulation tissue and residual\n malacia, however, with good airway patency. The scope was\n removed from the airways, and the patient recovered from his\n sedation\n .\n FDG :\n IMPRESSION: 1. Significant increase in soft mass (SUV max 12.8)\n consistent with known squamous cell carcinoma recurrence which now\n aligns the right paraspinal region and posteromedial pleural space. 2.\n New FDG-avid mediastinal lymph nodes as discussed above which are not\n pathologically enlarged consistent with metastatic disease.\n 3. New vertebral body compression deformities.\n 4. Slight increase in size of previously demonstrated FDG-avid (SUV max\n 23.7) left posterior parotid mass which is unlikely related to the\n squamous cell lung carcinoma.\n .\n SPIROMETRY, LUNG VOLUMES, DLCO\n Impression: Moderate restrictive ventilatory defect with a moderate to\n marked gas exchange defect. The reduced FEV1/FVC ratio indicates a\n coexisting obstructive ventilatory defect. The distance attained\n during the 6-minute walk test suggests a marked decrease in exercise\n capacity. Compared to the prior study of the FVC has\n increased by 0.47 L (+37%) and the FEV1 has increased by 0.32 L (+43%)\n while the TLC and DLCO have not changed significantly.\n ECG: EKG: pending\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap)\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes. Given history of worsening somnolence, likely\n worsening hypercarbia/OSA.\n - sputum culture\n - Iv solumedrol\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - per IP, would like to treat empirically for pneumonia; will treat\n with cefepime/vanco given recent instrumentation\n - portable CXR\n - EKG\n - BiPAP overnight\n - continue Mucomyst, Mucinex, Advair\n .\n # Chronic respiratory acidosis: Seen on ABG drawn at Chest center\n - will re-send ABG in MICU\n - BiPAP overnight\n .\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on Wednesday to exchange stent and debridement\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet\n # PPX: omeprazole (home), heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient)\n # CONTACT: (daughter) \n # DISPO: ICU for now\n , MD, MPH\n PGY-3\n \n ICU Care\n Nutrition:\n Comments: cardiac healthy diet\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2163-09-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 483776, "text": "Chief Complaint: Somnolence and hypoxia s/p bronchoscopy.\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 Admitted. Stable overnight. Declined bipap after 30minute trial.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n azithromycin , methylprednisonlone 125 iv q8, albuterol atroven,\n advair, fentanyl patch, HCTZ, synthroid, MVi, simvastatin, quinipril,\n naproxen, lopressor, mucinex.\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 09:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.9\nC (96.6\n HR: 95 (79 - 113) bpm\n BP: 117/57(69) {88/40(53) - 141/79(93)} mmHg\n RR: 20 (15 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 545 mL\n PO:\n 545 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 780 mL\n 550 mL\n Urine:\n 780 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -235 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 492 (492 - 492) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 0 cmH2O\n SpO2: 90%\n ABG: 7.43/62/69/39/13\n Ve: 11.2 L/min\n PaO2 / FiO2: 69\n Physical Examination\n General Appearance: No(t) Well nourished, 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: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Rhonchorous: )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.4 g/dL\n 659 K/uL\n 148 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 5.3 mEq/L\n 11 mg/dL\n 90 mEq/L\n 133 mEq/L\n 32.9 %\n 21.0 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n WBC\n 20.8\n 21.0\n Hct\n 31.9\n 32.9\n Plt\n 614\n 659\n Cr\n 0.5\n 0.5\n TCO2\n 43\n Glucose\n 93\n 148\n Other labs: Ca++:9.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Imaging: CXR Rt costophrenic area iwth thickening. no consolidation\n Microbiology: Sputum culture pending\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA):\n s/p Y stent, plan for OR for replacement of stent in am. NPO tonight.\n COPD/OSA: patient intolerant of Bipap. stabilized with clearing of\n sedation. currently ABG much improved. continue steroids at lower dose\n x 3 days 60mg solumdedrol .\n NSCLC: likely recurrence in RLL, options appear to be limited. be\n a candidate for paliative chemotherapy.\n Leukocytosis: ? related to steroids, vs malignancy and leukamoid\n reaction. will pan culture, no infiltrate on CXR, but significant\n secretions per patient will follow up sputum culture to r/o other more\n resistant bacterial pathogens. Will contineu azithro for COPD\n exacerbation.\n ICU Care\n Nutrition: po diet.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483682, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483706, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Events: Pt refused BiPap overnight. Tolerating 3 L NC 02 with good\n Sats\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Dyspneic with activity, states he feels about the same as he has felt\n over the last 2 weeks, junky sounding productive cough of thick\n whitish-tan sputum, lungs clear upper lobes with scattered rhonchi and\n lung sounds diminished at right base, 02 at 3 L NC with RR= 16-27 and\n Sats 84-99%. Albuterol/atrovent/ and mucomyst nebs overnight.\n Episodes of deSaturation when 02 off face---Sat recovers quickly,\n Easily arouseable and rested in naps during night, denies\n pain---fentanyl patch as ordered. Placed on BiPap at bedtime and pt\n tolerated it for appox. 20 minutes then pt removed mask and said it was\n just too uncomfortable and he declined to wear the bipap mask for the\n remainder of the night---MICU team aware\n Action:\n Maintained on 3L NC 02 (home regime), refusing biPap, nebs as ordered,\n IV solumedrol\n Response:\n Stable resp. status at present time. Maintaining Sats on 3 L 02 NC.\n Last ABG with improved CO2 levels\n Plan:\n Maintain airway, maintain sats, continue iv steroid doses, plan to go\n to OR on Wed. for stent replacement and debridement\n" }, { "category": "Nursing", "chartdate": "2163-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483708, "text": "Mr. is a 67 y.o. M with end stage COPD on home O2 3 L NC,\n tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell\n carcinoma with Cyberknife treatment in . Patient had Y-stent placed\n in complicated by cough and copious secretions requiring\n multiple therapeutic aspirations. Last bronchoscopy was at OSH,\n where patient had copious secretions that were aspirated. Pt reports\n compliance with Mucomyst nebs and Mucinex. He wears O2 \"almost\" 24\n hours/day, but always at night. He does not wear his CPAP. Endorses\n inability to expectorate secretions and having \"full feeling\" for \n weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased\n activity tolerance. Smokes 5 cig/day. PET scan in revealed FDG\n avid soft tissue mass adjacent to RUL resection site with some FDG avid\n nodes concerning for recurrence.\n .\n The patient had a scheduled bronchoscopy on day of admission at \n due to increased secretions and some changes in mental status.\n Reportedly, he was difficult to sedate and was given versed 8 mg and\n fentanyl 200 mcg. Bronchoscopy showed no complete opacification,\n secretions on R and granulation on R that was non-obstructing. After\n procedure, the patient was very difficult to arouse after the procedure\n and had episodes of respiratory depression with oxygen saturation\n dropping down to the low 70s requiring supplementation with high FIO2\n using non- rebreather mask. After about 5 minutes, the patient started\n to regain his respiratory drive and his oxygen saturation picked up to\n the 90s.\n .\n Pt is being admitted for bipap overnight with add-on case to OR on\n Wednesday for stent replacement and debridement.\n Events: Pt refused BiPap overnight. Tolerating 3 L NC 02 with good\n Sats\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Dyspneic with activity, states he feels about the same as he has felt\n over the last 2 weeks, junky sounding productive cough of thick\n whitish-tan sputum, lungs clear upper lobes with scattered rhonchi and\n lung sounds diminished at right base, 02 at 3 L NC with RR= 16-27 and\n Sats 84-99%. Albuterol/atrovent/ and mucomyst nebs overnight.\n Episodes of deSaturation when 02 off face---Sat recovers quickly,\n Easily arouseable and rested in naps during night, denies\n pain---fentanyl patch as ordered. Placed on BiPap at bedtime and pt\n tolerated it for appox. 20 minutes then pt removed mask and said it was\n just too uncomfortable and he declined to wear the bipap mask for the\n remainder of the night---MICU team aware\n Action:\n Maintained on 3L NC 02 (home regime), refusing biPap, nebs as ordered,\n IV solumedrol\n Response:\n Stable resp. status at present time. Maintaining Sats on 3 L 02 NC.\n Last ABG with improved CO2 levels\n Plan:\n Maintain airway, maintain sats, continue iv steroid doses, plan to go\n to OR on Wed. for stent replacement and debridement\n" }, { "category": "Respiratory ", "chartdate": "2163-09-13 00:00:00.000", "description": "Generic Note", "row_id": 483711, "text": "TITLE:\n Resp Care: Pt placed on noninvasive ventilation with full face mask for\n hypercarbia/marginal oxygenation post bronch; tol only ~30 minutes\n before removing mask and refusing replacement, changed to 02 3lpm\n maintaining sp02 84-99% with little pul reserve. Will cont NIV if\n needed.\n" }, { "category": "Physician ", "chartdate": "2163-09-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 483648, "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 67M COPD, TBM, y-stent in place and longstanding problem with ,\n congestion, dyspnea. His respiratory status has been worsening on a\n subacute basis. Presented today because of worsening SOB and somnolence\n for bronch.\n During bronch, secretions seen throughout right. Post-bronch\n complicated by somnolence, hypoxemia and hypoventialtion. He was put on\n higher O2 and improved.\n Plan is for stent replacement in 2 days in OR.\n 24 Hour Events:\n History obtained from housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n COPD\n TBM - s/p Y-stent\n RUL resection NSCLCa.\n recurrent NSCLCa. - s/p CK, recent concerning PET/CT for progressive\n disease in RLL and LNs\n active smoker\n OSA - untreated\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 05:49 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 105 (103 - 105) bpm\n BP: 141/59(77) {141/59(77) - 141/59(77)} mmHg\n RR: 28 (22 - 28) insp/min\n SpO2: 87%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 87% 3L NC\n ABG: ////\n Physical Examination\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: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : )\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Resp distress post bronch - status has been worsening over past number\n of weeks. Has a number of possible explanations including COPD,\n infection, progressive TBM and cancer progression. Will treat COPD\n flare with steroids, bronchodilators, antibiotics. Check CXR. BIPAP\n overnight. Stent replacement per IP.\n Lung cancer - does not appear that there are treatment options.\n Continue supportive care.\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2163-09-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 483818, "text": "Chief Complaint: Respiratory failure\n 24 Hour Events:\n EKG - At 05:36 PM\n NON-INVASIVE VENTILATION - START 06:08 PM\n - admitted yesterday afternoon\n - attempted Bipap but pt only tolerated for a few hours and then slept\n with 3 L NC instead\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 87 (79 - 113) bpm\n BP: 88/40(53) {88/40(53) - 141/79(93)} mmHg\n RR: 15 (15 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 545 mL\n PO:\n 545 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 780 mL\n 550 mL\n Urine:\n 780 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -235 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (492 - 492) mL\n PS : 10 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.43/62/69/39/13\n Ve: 11.2 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 659 K/uL\n 9.4 g/dL\n 148 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 5.3 mEq/L\n 11 mg/dL\n 90 mEq/L\n 133 mEq/L\n 32.9 %\n 21.0 K/uL\n [image002.jpg]\n 06:26 PM\n 06:48 PM\n 03:31 AM\n WBC\n 20.8\n 21.0\n Hct\n 31.9\n 32.9\n Plt\n 614\n 659\n Cr\n 0.5\n 0.5\n TCO2\n 43\n Glucose\n 93\n 148\n Other labs: Ca++:9.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap)\n .\n # COPD exacerbation: Likely in flare given decreased BS in lung exam,\n diffuse wheezes.\n - f/u sputum culture\n - solumedrol 60mg IV bid\n - standing albuterol / ipratropium\n - O2 goal 88-93%\n - treat with azithryomycin x 5 days for increased sputum production\n - consider retrying BIPAP if pt agreeable\n - continue Mucomyst, Mucinex, Advair\n .\n # Leukocytosis:\n - add on diff\n - check UA/Ucx and blood cx for further evaluation\n .\n # Chronic respiratory acidosis: Given history of worsening somnolence,\n likely worsening hypercarbia/OSA in setting of not using CPAP. Now\n improved. Reck ABG if worsening somnolence\n - BiPAP\n - ABGs\n .\n # Tracheobronchomalacia\n - appreciate IP recs\n - OR on Wednesday to exchange stent and debridement\n - NPO past M/N\n .\n # Squamous cell CA: Rad onc Dr \n - f/u Dr. as outpatient\n .\n # HTN:\n - continue metoprolol tartrate, quinapril and HCTZ\n .\n # Hyperlipidemia:\n - continue simvastatin\n .\n # Hypothyroidism:\n - continue levothyroxine\n .\n # Pain:\n - continue naprosyn and fentanyl patch\n - percocet prn pain\n .\n # Gout:\n - Allopurinol 100 mg po daily\n .\n # FEN: no IVFs / replete lytes prn / cardiac diet, NPO after MN for OR\n # PPX: omeprazole (home), heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL (confirmed with patient). If pt requiring aggressive life\n saving measures x 3 days, would prefer to withdraw care.\n # CONTACT: (daughter) \n # DISPO: ICU for now\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control:\n Lines:\n 22 Gauge - 05:06 PM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:19 ------\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484044, "text": "67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Returned from the or at 1230. Ip was unable to replace stent. Lots of\n purulent secretions in old stent. Old stent was removed and bronch\n done to clear secretions. Arrived in unit coughing without raising.\n Sats mid 90\ns on 3l facemask.\n Action:\n Lidocaine neb ordered and given as well as 30mg iv codeine phosphate.\n Response:\n On 3l fm sats low 90\ns. Back to pre OR resp status. Not as many\n secretions though.\n Plan:\n Plan is for pt to evaluate to see how patient does walking to see if he\n is safe for home. ? d/c home and return per ip for new stent.\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 484090, "text": "67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Returned from the or at 1230. Ip was unable to replace stent. Lots of\n purulent secretions in old stent. Old stent was removed and bronch\n done to clear secretions. Arrived in unit coughing without raising.\n Sats mid 90\ns on 3l facemask.\n Action:\n Lidocaine neb ordered and given as well as 30mg iv codeine phosphate.\n Response:\n On 3l fm sats low 90\ns. Back to pre OR resp status. Not as many\n secretions though.\n Plan:\n Plan is for pt to evaluate to see how patient does walking to see if he\n is safe for home. ? d/c home and return per ip for new stent.\n Review of systems-\n Neuro- alert and oriented x3. cooperative with care.\n Resp- on 3l nc with sats high 80\ns to low 90\ns. resp mid teens to low\n 20\ns. desats with activity. Recovers with rest. Coughs and is able to\n raise at times thick grey tan green sputum. rhonchorous upper. BS\n diminished at the bases. Unable to wear bipap at night.\n Cardiac- hr 70-90\ns nsr. Sbp 90-120\n Gi- on heart healthy diet. Tolerates this well. Last moved bowels .\n Gu- voids in urinal clear yellow urine.\n Access- #20 in right forearm from .\n Social- has 2 daughters and .\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERCARBIC RESPIRATORY DISTRESS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 64.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD\n CV-PMH: CAD, Hypertension\n Additional history: Squamous Cell CA s/p RUL loectomy and cyberknife\n treatment 05,\n Stent placement with cardiac arrest\n OSA on CPAP but he is non compliant with it- home o2 use\n Hypothyroidism, Gout , Hypercholesteolemia\n + cig use , compresssion FX- Fentanyl patch\n TRAchaelbroncheal malacia- severe- with y stent placement \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:54\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 29 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 2,270 mL\n 24h total out:\n 3,200 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 03:25 AM\n Potassium:\n 5.1 mEq/L\n 03:25 AM\n Chloride:\n 91 mEq/L\n 03:25 AM\n CO2:\n 38 mEq/L\n 03:25 AM\n BUN:\n 15 mg/dL\n 03:25 AM\n Creatinine:\n 0.6 mg/dL\n 03:25 AM\n Glucose:\n 121 mg/dL\n 03:25 AM\n Hematocrit:\n 30.9 %\n 03:25 AM\n Finger Stick Glucose:\n 141\n 06:00 PM\n Valuables / Signature\n Patient valuables: Dentures: (Upper )\n Other valuables:\n Clothes: Sent home with: daughters\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 786\n Transferred to: CC716\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2163-09-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 484089, "text": "67 y.o. M with end stage COPD, tracheobronchomalacia s/p Y-stent, s/p\n RUL resection for squamous cell carcinoma with Cyberknife treatment in\n , s/p flex bronchoscopy, now admitted to MICU for COPD exacerbation\n and closer respiratory monitoring (needing bipap).\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Returned from the or at 1230. Ip was unable to replace stent. Lots of\n purulent secretions in old stent. Old stent was removed and bronch\n done to clear secretions. Arrived in unit coughing without raising.\n Sats mid 90\ns on 3l facemask.\n Action:\n Lidocaine neb ordered and given as well as 30mg iv codeine phosphate.\n Response:\n On 3l fm sats low 90\ns. Back to pre OR resp status. Not as many\n secretions though.\n Plan:\n Plan is for pt to evaluate to see how patient does walking to see if he\n is safe for home. ? d/c home and return per ip for new stent.\n Review of systems-\n Neuro- alert and oriented x3. cooperative with care.\n Resp- on 3l nc with sats high 80\ns to low 90\ns. resp mid teens to low\n 20\ns. desats with activity. Recovers with rest. Coughs and is able to\n raise at times thick grey tan green sputum. rhonchorous upper. BS\n diminished at the bases. Unable to wear bipap at night.\n Cardiac- hr 70-90\ns nsr. Sbp 90-120\n Gi- on heart healthy diet. Tolerates this well. Last moved bowels .\n Gu- voids in urinal clear yellow urine.\n Access- #20 in right forearm from .\n Social- has 2 daughters and .\n" }, { "category": "Radiology", "chartdate": "2163-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1097934, "text": " 5:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: HYPERCARBIC RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with COPD exacerbation\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n WET READ: AGLc MON 10:33 PM\n right costophrenic angle thickening and left basilar atelectasis as before. no\n focal airspace consolidation seen.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: COPD exacerbation, evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no major change.\n Asymmetry of the hemithoraces given the past post-operative history. No newly\n occurred focal parenchymal opacities suggesting pneumonia. Pre-existing\n minimal scarring at the left and right lung base are unchanged. No evidence\n of pleural effusion. No overhydration. No evidence of tumor recurrence.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2154-06-20 00:00:00.000", "description": "Report", "row_id": 89261, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 72\nWeight (lb): 200\nBSA (m2): 2.13 m2\nBP (mm Hg): 100/70\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith <35% decrease during respiration (estimated RA pressure indeterminate).\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: Mildly dilated aortic sinus. Moderately dilated ascending aorta. Mildly\ndilated aortic arch. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrial pressure is indeterminate.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The ascending aorta is moderately dilated. The aortic arch is\nmildly dilated. 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. The left ventricular inflow pattern suggests\nimpaired relaxation. The estimated pulmonary artery systolic pressure is\nnormal. There is a trivial/physiologic pericardial effusion. There is an\nanterior space which most likely represents a fat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal\nbiventricular systolic function. Moderately dilated ascending aorta.\n\n\n" }, { "category": "Echo", "chartdate": "2154-06-21 00:00:00.000", "description": "Report", "row_id": 89253, "text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for CABG\nHeight: (in) 72\nWeight (lb): 200\nBSA (m2): 2.13 m2\nStatus: Inpatient\nDate/Time: at 13:46\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace 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: 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. See Conclusions for post-bypass data The\npost-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium and right atrium are normal in cavity size. No atrial\nseptal defect is seen by 2D or color Doppler.\n2. Left ventricular wall thickness, cavity size, and global systolic function\nare normal (LVEF>55%). Overall left ventricular systolic function is normal\n(LVEF>55%).\n3. Right ventricular chamber size and free wall motion are normal.\n4. The diameters of aorta at the sinus, ascending and arch levels are normal.\nThere are simple atheroma in the descending thoracic aorta.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. There is no aortic valve stenosis. Trace aortic regurgitation is\nseen.\n6. The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n7. There is no pericardial effusion.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including phenylephrine and is in sinus rhythm.\n\nMid-esophageal views are very sub-optimal.\n1. Biventricular function is intact.\n2. Arch and descending aorta are intact.\n\nDr. was notified in person of the results.\n\n\n" }, { "category": "ECG", "chartdate": "2154-06-21 00:00:00.000", "description": "Report", "row_id": 233956, "text": "Sinus rhythm. A-V conduction delay. Prior inferior myocardial infarction. Left\nanterior fascicular block. Borderline low limb lead voltage, diminished as\ncompared to the previous tracing of . The rate has increased. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2154-06-20 00:00:00.000", "description": "Report", "row_id": 233957, "text": "Compared to the previous tracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2154-06-19 00:00:00.000", "description": "Report", "row_id": 233958, "text": "Normal sinus rhythm, rate 62, with some sinus arrhythmia. Medium grade\nventricular ectopy. Probable inferior myocardial infarction of indeterminate\nage. Left axis deviation. Lead V2 is not available for analysis. No previous\ntracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2154-06-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1084662, "text": " 3:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film- contact NP # if abnormal- will be\n Admitting Diagnosis: CAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film- contact NP # if abnormal- will be in CVICU approx.\n 2:15 PM - please call first\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , there has been a CABG procedure\n performed. Intact midline sternal sutures are seen. Endotracheal tube tip\n lies above the clavicular level, approximately 8 cm above the carina. Right\n IJ Swan-Ganz catheter extends to the right pulmonary artery. Nasogastric tube\n extends to the upper stomach with the side hole in the region of the\n esophagogastric junction. Left chest tube is in place with no definite\n pneumothorax. There is atelectatic change at both bases. Scattered gas is\n seen within the mediastinum.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1084925, "text": " 1:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with s/p cabg, CTs d/c'd\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest radiograph of with comparison to \n and indication of chest tube removal.\n\n FINDINGS: Various indwelling devices have been removed, with no evidence of\n pneumothorax. Cardiomediastinal contours are unchanged in appearance in the\n postoperative period. Patchy areas of atelectasis are present in both\n retrocardiac regions, and a small left pleural effusion is also demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-06-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1085243, "text": " 10:49 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , there are small bilateral pleural\n effusions. Little change in the appearance of the cardiac silhouette. Patchy\n area of increased opacification at the bases.\n\n\n" }, { "category": "Respiratory ", "chartdate": "2154-06-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 580990, "text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Pt received from OR,\n" }, { "category": "Nursing", "chartdate": "2154-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 581093, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Neuro: A&Ox3, MAE and follows commands. C/O pain despite IV Dilaudid.\n Incisional pain over chest tubes.\n CV: Hemodynamically stable.. Tachy up to 120. Map 60-70 off pressors.\n Pedal pulses palpable.\n Resp: Stable post extubation w/ 02sats 95-100% on 50% face tent. LS\n diminished, clear.\n Renal: Brisk u/o. Lytes wnl. Fluid balance +350 this am. Endo: BS down\n to 67.\n GI: Sl nausea overnoc. Hypoactive BS. Tolerating pills with water.\n Heme: stable ID: Afebrile. Skin: intact.\n Action:\n Started on torodol IM. Swan d/ced. 1 liter fluid bolus then 25mg po\n Lopressor given. Reglan given for nausea. Insulin gtt weaned off.\n Switched to 4lnp.\n Response:\n Remains calm and appropriate. Improved pain control with torodol. Hr\n down 80\ns nsr. MAP 60. Stable 02sats. Nausea resolved. BS 99.\n Plan:\n Cont to monitor. IS and pulm toilet. Lopressor if BP allows. Pain\n control with torodol alternating with po percocet or Dilaudid. Deline\n and oob-chair. Advance diet. Cont teaching and emotional support.\n Ready pt for transfer to floor.\n" }, { "category": "Physician ", "chartdate": "2154-06-22 00:00:00.000", "description": "ICU Note - CVI", "row_id": 581214, "text": "CVICU\n HPI:\n HD4\n POD 1\n 64M s/p CABG x4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) \n EF: 60% Wt. 91.2 Cr.: 1.0 HgbA1c: 6.2\n PMHx: HTN, diet controlled DM, hyperlipidemia, s/p melanoma resection\n : Crestor 5', Lisinopril/HCTZ 10/12.5', Amlodipine 2.5', Atenolol\n 25', MVI 1', Vit E 400 IU , 162'\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 2. Aspirin EC 3. Bisacodyl 4. Docusate Sodium 5.\n Furosemide 6. Insulin 7. Metoprolol Tartrate\n 8. Milk of Magnesia 9. Oxycodone-Acetaminophen 10. Potassium Chloride\n 11. Ranitidine 12. Rosuvastatin Calcium\n 13. Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 02:44 PM\n CORDIS/INTRODUCER - START 02:45 PM\n PA CATHETER - START 02:45 PM\n ARTERIAL LINE - START 02:45 PM\n INVASIVE VENTILATION - START 02:50 PM\n NASAL SWAB - At 03:00 PM\n EKG - At 03:07 PM\n EXTUBATION - At 05:58 PM\n INVASIVE VENTILATION - STOP 05:58 PM\n PA CATHETER - STOP 03:01 AM\n Post operative day:\n HD4\n POD 1\n 64M s/p CABG x4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:00 PM\n Hydromorphone (Dilaudid) - 09:00 PM\n Ranitidine (Prophylaxis) - 10:00 AM\n Other medications:\n Flowsheet Data as of 05:37 PM\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: 37.3\nC (99.1\n HR: 79 (79 - 111) bpm\n BP: 112/59(67) {85/53(61) - 112/60(68)} mmHg\n RR: 10 (8 - 21) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n CVP: 7 (7 - 14) mmHg\n PAP: (23 mmHg) / (13 mmHg)\n CO/CI (Thermodilution): (6.37 L/min) / (4 L/min/m2)\n SVR: 612 dynes*sec/cm5\n SV: 80 mL\n SVI: 37 mL/m2\n Total In:\n 6,544 mL\n 1,939 mL\n PO:\n 600 mL\n Tube feeding:\n IV Fluid:\n 6,044 mL\n 1,339 mL\n Blood products:\n 500 mL\n Total out:\n 2,190 mL\n 1,285 mL\n Urine:\n 1,860 mL\n 1,075 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 4,354 mL\n 654 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 95%\n ABG: 7.41/40/91/27/0\n PaO2 / FiO2: 182\n Physical Examination\n General Appearance: No acute distress\n HEENT: Pupils fixed and dilated, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, hypoactive, softly\n distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 201 K/uL\n 11.1 g/dL\n 83 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 103 mEq/L\n 138 mEq/L\n 30.9 %\n 10.3 K/uL\n [image002.jpg]\n 01:22 PM\n 01:54 PM\n 01:57 PM\n 03:03 PM\n 03:06 PM\n 05:46 PM\n 09:04 PM\n 09:09 PM\n 01:13 AM\n 01:20 AM\n WBC\n 12.2\n 15.2\n 10.3\n Hct\n 33\n 35\n 30.8\n 34.1\n 32.0\n 30.9\n Plt\n 179\n 228\n 201\n Creatinine\n 0.8\n 0.6\n TCO2\n 29\n 31\n 26\n 30\n 26\n Glucose\n 185\n 130\n 105\n 123\n 83\n Other labs: PT / PTT / INR:13.1/27.5/1.1, Fibrinogen:317 mg/dL, Lactic\n Acid:2.5 mmol/L\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE II, CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: HD4\n POD 1\n 64M s/p CABG x4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) \n Hemodynamically stable, doing well.\n Neurologic: Neuro checks Q: 4 hr, Torodol/PCT prn pain. OOB->chair. PT\n eval\n Cardiovascular: Aspirin, Beta-blocker, Statins, Hemodynamically stable.\n Optimize B-Blocker as BP tols.PWs in.\n Pulmonary: IS, Encourage DB&C,IS gentle diuresis\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated , Cont bowel regiment/prophylaxis\n Renal: Foley, Adequate UO, BUN/Cr=13/0.6, gentle diuresis\n Hematology: Stable. No issues\n Endocrine: Humolog SS\n Infectious Disease: Check cultures, No issues\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, P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Humalog SS\n Lines:\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:\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2154-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 581019, "text": "64 year old male + ekg changes on routine physical ,+ett, Cath revealed\n 3 vcad\n Coronary artery bypass graft (CABG)lima to lad, svg to ,,+pda.\n Assessment:\n Sr-st with isolated pvc/pac, sbp 90-110\ns, ci>2 , cool to warm and dry\n extremities, + pp, min ct drainage. Hct 32,autodiuresing, ^ pain\n Action:\n Pacer off, v capture not checked due to st, 4 l lr given, extubated at\n 1800 without incident. Is 750 , 40 meq kcl+ 2 gm magnesium given.\n Morphine 6 mg total , iv Dilaudid\n Response:\n Sr-st\n no further ectopy,diuresing, stable post cabg. Fair effect from\n morphine, good effect from dilaudid\n Plan:\n Monitor comfort, hr and rythym, sbp, ci, ct drainage, pp, resp\n status-pulm toilet, neuro status, i+o, labs pending. Transfer to floor\n in am\n Diabetes Mellitus (DM), Type II\n Assessment:\n Glucose > 120\n Action:\n Insulin gtt initiated at 1800.\n Response:\n 2200 glucose 119\n Plan:\n Monitor glucose q1hr , as per protocol.\n" }, { "category": "Nursing", "chartdate": "2154-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581199, "text": "TITLE:\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CAD\n Code status:\n Height:\n 72 Inch\n Admission weight:\n 91.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: hyperlipidemia,s/p resection of melanoma of face\n and nose.school custodian,etoh 4 doubles / weekend.\n Surgery / Procedure and date: cabg x 4 lima to lad, svg to\n ,,pda. ez intubation, vanco+cipro @ 1000, cbp 97',xc74',ef\n 60%,cry 1400ml, cs 500,uo 850, no issues in or. out on propofol, min ct\n drainage. sr 80's,/ extubated at 1800. lr 3 l given. insulin gtt.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:59\n Temperature:\n 99.1\n Arterial BP:\n S:82\n D:51\n Respiratory rate:\n 10 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,939 mL\n 24h total out:\n 1,285 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.2 mV\n Temporary atrial sensitivity setting:\n 0.6 mV\n Temporary atrial stimulation threshold :\n 7 mA\n Temporary atrial stimulation setting:\n 14 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2 mV\n Temporary ventricular stimulation threshold :\n 2.5 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:13 AM\n Potassium:\n 4.0 mEq/L\n 01:13 AM\n Chloride:\n 103 mEq/L\n 01:13 AM\n CO2:\n 27 mEq/L\n 01:13 AM\n BUN:\n 13 mg/dL\n 01:13 AM\n Creatinine:\n 0.6 mg/dL\n 01:13 AM\n Glucose:\n 83 mg/dL\n 01:13 AM\n Hematocrit:\n 30.9 %\n 01:13 AM\n Finger Stick Glucose:\n 164\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n peripheral x2\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2154-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581200, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n 64 yo + ekg changes on routine physical, +ETT, cath revealed 3VD. \n cabg x4. lima to lad, svg to , svg to om, svg to pda. Stable post\n period. Vss w/ sbp running low 90\ns. had received lopressor 25mg po\n this am. NSR 80\ns. no ect noted. CT remain w/ mod sang dng w/ pt oob\n to ch. Lungs clear bilat. O2 sats mid 90\ns on r/a. abd soft. Bs hypo.\n No nausea. Appetite good. 1200 BS 164. percocets 2 tab alt w/ toradol\n 15 mg IM. Pain 5/ 10, acceptable to pt and doing well w/ pulm hygiene\n Action:\n Analgesia\n Oob to ch w/ min assist of 2\n Using IS independently\n Lopressor decreased to 12.5 mg\n Insulin 6 unit reg at 1230 -> changed to humolog on transfer\n Response:\n Stable pot-op day 1\n Plan:\n Transfer farrr6, cont cardiac pathway.\n" }, { "category": "Nursing", "chartdate": "2154-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581201, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n 64 yo + ekg changes on routine physical, +ETT, cath revealed 3VD. \n cabg x4. lima to lad, svg to , svg to om, svg to pda. Stable post\n period. Vss w/ sbp running low 90\ns. had received lopressor 25mg po\n this am. NSR 80\ns. no ect noted. CT remain w/ mod sang dng w/ pt oob\n to ch. Lungs clear bilat. O2 sats mid 90\ns on r/a. abd soft. Bs hypo.\n No nausea. Appetite good. 1200 BS 164. percocets 2 tab alt w/ toradol\n 15 mg IM. Pain 5/ 10, acceptable to pt and doing well w/ pulm hygiene\n Action:\n Analgesia\n Oob to ch w/ min assist of 2\n Using IS independently\n Lopressor decreased to 12.5 mg\n Insulin 6 unit reg at 1230 -> changed to humolog on transfer\n Response:\n Stable pot-op day 1\n Plan:\n Transfer farrr6, cont cardiac pathway.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CAD\n Code status:\n Height:\n 72 Inch\n Admission weight:\n 91.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: hyperlipidemia,s/p resection of melanoma of face\n and nose.school custodian,etoh 4 doubles / weekend.\n Surgery / Procedure and date: cabg x 4 lima to lad, svg to\n ,,pda. ez intubation, vanco+cipro @ 1000, cbp 97',xc74',ef\n 60%,cry 1400ml, cs 500,uo 850, no issues in or. out on propofol, min ct\n drainage. sr 80's,/ extubated at 1800. lr 3 l given. insulin gtt.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:59\n Temperature:\n 99.1\n Arterial BP:\n S:82\n D:51\n Respiratory rate:\n 10 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,939 mL\n 24h total out:\n 1,285 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.2 mV\n Temporary atrial sensitivity setting:\n 0.6 mV\n Temporary atrial stimulation threshold :\n 7 mA\n Temporary atrial stimulation setting:\n 14 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2 mV\n Temporary ventricular stimulation threshold :\n 2.5 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:13 AM\n Potassium:\n 4.0 mEq/L\n 01:13 AM\n Chloride:\n 103 mEq/L\n 01:13 AM\n CO2:\n 27 mEq/L\n 01:13 AM\n BUN:\n 13 mg/dL\n 01:13 AM\n Creatinine:\n 0.6 mg/dL\n 01:13 AM\n Glucose:\n 83 mg/dL\n 01:13 AM\n Hematocrit:\n 30.9 %\n 01:13 AM\n Finger Stick Glucose:\n 164\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n peripheral x2\n Valuables / Signature\n Patient valuables: glasses\n Other valuables:\n Clothes: Sent home with: 6 w/ pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: cvicu B\n Transferred to: 6\n Date & time of Transfer: 1530\n" }, { "category": "Respiratory ", "chartdate": "2154-06-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 581005, "text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Pt received from OR, S/P CABG x4, intubated and vented on settings as\n per resp. flowsheet. Pt stable post-op and fast track weaned to\n extubation. Currently on 50% face tent.\n" }, { "category": "Nursing", "chartdate": "2154-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581191, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n 64 yo + ekg changes on routine physical, +ETT, cath revealed 3VD. \n cabg x4. lima to lad, svg to diag, svg to om, svg to pda. Stable post\n period. Vss w/ sbp running low 90\ns. had received lopressor 25mg po\n this am. NSR 80\ns. no ect noted. CT remain w/ mod sang dng w/ pt oob\n to ch. Lungs clear bilat. O2 sats mid 90\ns on r/a. abd soft. Bs hypo.\n No nausea. Appetite good. 1200 BS 164. percocets 2 tab alt w/ toradol\n 15 mg IM. Pain 5/ 10, acceptable to pt and doing well w/ pulm hygiene\n Action:\n Analgesia\n Oob to ch w/ min assist of 2\n Using IS independently\n Lopressor decreased to 12.5 mg\n Insulin 6 unit reg at 1230 -> changed to humolog on transfer\n Response:\n Stable pot-op day 1\n Plan:\n Transfer farrr6, cont cardiac pathway.\n" }, { "category": "Nursing", "chartdate": "2154-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581197, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n 64 yo + ekg changes on routine physical, +ETT, cath revealed 3VD. \n cabg x4. lima to lad, svg to diag, svg to om, svg to pda. Stable post\n period. Vss w/ sbp running low 90\ns. had received lopressor 25mg po\n this am. NSR 80\ns. no ect noted. CT remain w/ mod sang dng w/ pt oob\n to ch. Lungs clear bilat. O2 sats mid 90\ns on r/a. abd soft. Bs hypo.\n No nausea. Appetite good. 1200 BS 164. percocets 2 tab alt w/ toradol\n 15 mg IM. Pain 5/ 10, acceptable to pt and doing well w/ pulm hygiene\n Action:\n Analgesia\n Oob to ch w/ min assist of 2\n Using IS independently\n Lopressor decreased to 12.5 mg\n Insulin 6 unit reg at 1230 -> changed to humolog on transfer\n Response:\n Stable pot-op day 1\n Plan:\n Transfer farrr6, cont cardiac pathway.\n" }, { "category": "Radiology", "chartdate": "2154-06-20 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1084442, "text": " 1:04 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: check veous conduit for CABG Bilateral veing mapping\n Admitting Diagnosis: CAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD\n REASON FOR THIS EXAMINATION:\n check veous conduit for CABG Bilateral veing mapping\n ______________________________________________________________________________\n FINAL REPORT\n Bilateral lower extremity greater saphenous mapping was performed preop CABG.\n\n FINDINGS:\n\n RIGHT: The right greater saphenous vein is patent with small diameters below\n the knee ranging from 0.8 to 1.0 mm. From the knee to the groin, the\n diameters are 2.0, 3.4, 2.4, 2.4, 3.2 mm respectively. The right lesser\n saphenous vein is patent but has small diameters ranging from 1.0-3.7 mm.\n\n LEFT: The left greater saphenous vein is patent with small diameters below\n the knee, ranging from 1.3 to 1.9 mm. From the knee to the groin, the\n diameters are 1.5, 5.5, 5.5 5.1, 4.6 mm respectively. The left lesser\n saphenous vein is not visualized.\n\n IMPRESSION: Patent greater saphenous veins with small diameters from the knee\n to the ankle. The left thigh diameters are best. Small diameter left lesser\n saphenous vein. The right lesser saphenous vein diameters are small.\n\n" }, { "category": "Radiology", "chartdate": "2154-06-20 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1084441, "text": " 1:03 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: eval for carotid stenosis\n Admitting Diagnosis: CAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man pre-op CABG\n REASON FOR THIS EXAMINATION:\n eval for carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n\n Standard Report Carotid US\n\n Study: Carotid Series Complete\n\n Reason: 64 year old man for pre-op CABG, eval for carotid stenosis\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is no plaque. On the left there is mild heterogeneous with\n intimal wall thickening plaque in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 43/18, 39/16, 72/24 cm/sec. CCA peak systolic\n velocity is 45 cm/sec. ECA peak systolic velocity is 70 cm/sec. The ICA/CCA\n ratio is 0.63. 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 25/10, 46/19, 67/29 cm/sec. CCA peak systolic\n velocity is 72 cm/sec. ECA peak systolic velocity is 74 cm/sec. The ICA/CCA\n ratio is 1.07. 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" }, { "category": "Radiology", "chartdate": "2154-06-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1084392, "text": " 9:30 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65 year-old man with CAD for evaluation of infiltrate or\n effusion.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST: The cardiomediastinal silhouette is unremarkable. The\n lungs are clear. There is no pleural effusion.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2149-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1156525, "text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESRD, respiratory distress\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory distress, pulmonary edema.\n\n COMPARISON: , 1:05 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is a marked\n deterioration. Newly occurred bilateral widespread ill-defined opacities,\n partially with air bronchograms. No pleural effusions. Constant size of the\n cardiac silhouette. The changes could be consistent with hyperpermeability\n pulmonary edema.\n\n The referring physician, . was paged for notification.\n Subsequently, the findings were discussed over the phone.\n\n" }, { "category": "Radiology", "chartdate": "2149-10-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1156495, "text": " 1:08 AM\n CHEST (PA & LAT) Clip # \n Reason: Eval acute intrathoracic process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with DOE, orthopnea\n REASON FOR THIS EXAMINATION:\n Eval acute intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with dyspnea on exertion and orthopnea.\n Evaluate for acute intrathoracic process.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL VIEWS: Lung volumes are low. There is linear opacity\n at the right lung base compatible with atelectasis. There is no appreciable\n pleural effusion or pneumothorax. No focal consolidation is identified. The\n patient is status post median sternotomy with multiple surgical clips, similar\n to prior. Heart size is normal. There is tortuosity of the thoracic aorta,\n but the mediastinal silhouette is otherwise unremarkable. Hilar contours and\n pulmonary vasculature are normal. There is no overt pulmonary edema. Surgical\n clips are noted in the right upper quadrant presumably related to prior\n cholecystectomy.\n\n IMPRESSION: No acute intrathoracic abnormality or significant change from\n prior.\n\n" }, { "category": "Echo", "chartdate": "2149-10-20 00:00:00.000", "description": "Report", "row_id": 78555, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath. Coronary artery disease. S/p CABG.\nHeight: (in) 68\nWeight (lb): 262\nBSA (m2): 2.29 m2\nBP (mm Hg): 104/65\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 10:39\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The rhythm\nappears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. The basal\ninferolateral wall appears to be relatively thin and hypokinetic. The\nremaining segments are grossly normal (LVEF ?50%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The ascending aorta is mildly dilated. The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar (technical quality was superior for the prior study)..\n\n\n" }, { "category": "ECG", "chartdate": "2149-10-20 00:00:00.000", "description": "Report", "row_id": 184802, "text": "Atrial fibrillation with rapid ventricular response. Incomplete right\nbundle-branch block. Possible prior inferior myocardial infarction. Lateral\nST segment depressions may be related to myocardial ischemia. Clinical\ncorrelation is suggested. Compared to tracing #1 the ventricular response\nis faster and there is less than one millimeter ST segment depression in the\nlateral leads, including the anterolateral leads.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2149-10-20 00:00:00.000", "description": "Report", "row_id": 184803, "text": "Atrial fibrillation. Incomplete right bundle-branch block. Possible prior\ninferior myocardial infarction. Compared to the previous tracing of \natrial fibrillation has replaced sinus rhythm.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2149-10-24 00:00:00.000", "description": "Report", "row_id": 184800, "text": "Atrial fibrillation with a moderate ventricular response. Incomplete right\nbundle-branch block. Lateral ST-T wave abnormalities. Cannot rule out\nmyocardial ischemia. Compared to the previous tracing of lateral\nST-T wave changes are more prominent. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2149-10-21 00:00:00.000", "description": "Report", "row_id": 184801, "text": "Atrial fibrillation. Leftward axis. RSR' pattern in leads V1-V2. QRS width\nis at least 110 milliseconds. Intraventricular conduction delay of right\nbundle-branch block type. ST-T wave abnormalities. Since the previous tracing\nof the rate is somewhat slower. R waves are more apparent in the\ninferior leads. There is less artifact.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-04-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823175, "text": " 9:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change, neutropenic man with fever, hypoxia,\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n\n REASON FOR THIS EXAMINATION:\n assess interval change, neutropenic man with fever, hypoxia, on vent\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP:\n\n INDICATION: Lung carcinoma with right pleural effusion. Patient intubated.\n Neutropenia, fever, hypoxia. On ventilator. Check status.\n\n FINDINGS: A single AP supine image.\n\n COMPARISON: .\n\n The endotracheal tube, the right IJ central line, NG line and right chest tube\n all remain in satisfactory positions. There appears to have been significant\n reduction in size of the right apical pneumothorax, associated with slight\n further shift of the heart and mediastinum to the right. A trace residual\n pneumothorax is still present. There is again evidence of\n collapse/consolidation of the underlying right upper lobe and some patchy\n bibasilar infiltrates are noted in the lower lobes. A small effusion is also\n present on the left side in the lower zone laterally. Some cardiac\n enlargement is again noted, mainly left ventricular. An ICD pacing electrode\n is in position.\n\n IMPRESSION:\n\n 1) Reduction in size of right pneumothorax. The appearances are otherwise\n essentially unchanged. Right upper lobe collapse/consolidation noted. Some\n patchy infiltrate in both lower lobes.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823606, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT placement\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n\n REASON FOR THIS EXAMINATION:\n check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 75-year-old male with lung cancer. Check position of the ET\n tube.\n\n AP supine single view of the chest is compared to .\n\n FINDINGS: ET tube is located approximately 3 cm from the carina. There is an\n NG tube extending below the limits of the radiograph in the stomach. There is\n a right-sided chest tube. There is interval increase in the right pleural\n effusion. There is a small amount of air in the right hemithorax consistent\n with hydropneumothorax. There is again noted volume loss in the right side\n consistent with postobstructive atelectasis. There are again noted multiple\n patchy opacities in the left lower lobe consistent with pneumonia and the\n moderate-sized left pleural effusion which is unchanged when compared to the\n previous study.\n\n IMPRESSION:\n 1. Interval increase in the right pleural effusion. There is still a small\n amount of air in the right hemithorax (hydropneumothorax).\n 2. Continued left lower lobe pneumonia with left pleural effusion. There is\n again noted the left subclavian ICDP.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 823955, "text": " 2:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: colonic distention?\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cdiff colitis, less diarrhea but rising wbc and clinical\n decline, assess for ? megacolon\n REASON FOR THIS EXAMINATION:\n colonic distention?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: C-Dif colitis and diarrhea. Evaluate for colonic distention.\n\n FINDINGS: NG tube is positioned with it's distal tip within the distal\n stomach. No evidence of ileus, obstruction, or free air. No dilated colonic\n loops are seen. The osseous structures are unremarkable.\n\n IMPRESSION: No evidence of free air or colonic dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823751, "text": " 11:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate right pleural effusion for further progression\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n\n REASON FOR THIS EXAMINATION:\n evaluate right pleural effusion for further progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right pleural effusion and respiratory failure. Followup.\n\n PORTABLE AP CHEST: Comparison is made to previous films from at 5:18.\n\n FINDINGS: All lines and tubes remain in place. There is some increased\n visualization of aerated lung in the right lower lung field. The left lung is\n stable with some pleural fluid layering out. The pulmonary vessels appear no\n different than prior and there is no evidence for new consolidation.\n\n There is continued evidence of opacification much of the right hemithorax.\n\n No pneumothorax.\n\n IMPRESSION:\n\n Some additional aerated lung is now visualized in the right lung base.\n Otherwise no significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823136, "text": " 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate central line placement, ETT placement, and characte\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n REASON FOR THIS EXAMINATION:\n evaluate central line placement, ETT placement, and characterize right pleural\n effusion/chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA and right pleural effusion. Intubated, evaluate placement\n of central line, ET and characterize right pleural effusion, chest tube\n placement.\n\n CHEST, SINGLE AP VIEW:\n\n An ET tube is present, tip in satisfactory position approximately 5.7 cm above\n the carina. A right IJ central line is present. The caradiomediastinal\n silhouettes are completely obscured due to the right hemithorax opacification,\n but the line tip most likely overlies the distal SVC. There is extensive\n opacification of the right hemithorax, likely with associated volume loss,\n including suspected slight elevation of the right hemidiaphragm and rightwar\n shift of the mediasintum. A right-sided chest tube is present, within normal\n limits in position. I cannot characterize the constituents of the right\n hemithorax opacity in this single view, but differential diagnosis includes\n fluid consolidation, mass and volume loss. I also cannot excluded a loculated\n pneumothorax on the right. On the left, there is patchy alveolar opacity\n scattered throughout the lungs, most prominent in the perihilar and left\n basilar location. The extreme left costophrenic angle is excluded from the\n film, but no gross effusion is seen. There is no upper zone redistribution to\n suggest CHF. A single-lead pacemaker is present, lead tip over right\n ventricle. A NG tube is present, tip over gastric antrum. No previous chest\n x-ray is available for comparison.\n\n IMPRESSION:\n\n 1. Considerable opacification of the right hemidiaphragm, with suspected small\n degree of volume loss. CT would be required to further characterize the\n components of the right hemithorax opacification and to exclude a loculated\n pneumothoorax and to definitively asses alignment of the mediastinum. Right\n chest tube and remaining lines and tubes as described.\n\n 2. Patchy alveolar opacity left lung. Differential diagnosis includes patchy\n atelectasis or infectious infiltrate. Atypical CHF is considered much less\n likely. Correlation with clinical context is requested, for full assessment.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 824091, "text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p L IJ TLC placement. Confirm placement in SVC.\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n getting photodynamic therapy\n REASON FOR THIS EXAMINATION:\n s/p L IJ TLC placement. Confirm placement in SVC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 y/o with lung cancer, assess left IJ line placement.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH: Comparison was made to study of\n earlier the same day.\n\n There has been interval placement of a left internal jugular central venous\n catheter with its tip terminating at the distal left subclavian vein. There\n is no left pneumothorax. There is persistent left pleural effusion, unchanged\n in appearance. A right hydropneumothorax is also unchanged in appearance.\n The endotracheal tube, right central venous catheter, right sided chest tube,\n NG tube, and pacing leads are unchanged.\n\n IMPRESSION:\n\n Interval placement of left IJ central venous catheter with its tip in the\n distal left subclavian vein. No pneumothorax. Unchanged left pleural\n effusion and right hydropneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823409, "text": " 12:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated has\n acute SOB and desat overnight\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 year old male with lung cancer and right pleural effusion.\n AP semiupright single view of the chest is compared to .\n\n FINDINGS: There is a right IJ central line with the tip in the mid SVC. There\n is a left chest wall ICD electrodes in unchanged position. There is an NG\n tube with the tip extending below the limits of the radiograph in the stomach.\n Previous radiograph from suggest that the NG tube tip is in the\n first portion of the duodenum. There is an ET tube with the tip in\n appropriate position. There is again noted volume loss in the right lung due\n to atelectasis and right pleural effusion. There is again noted a right-sided\n chest tube in unchanged position. There is no definite evidence of\n pneumothorax. The cardiac, mediastinal and hilar contours are unchanged in\n appearance. There are again noted patchy opacities in the left lower lobe\n which is associated with left pleural effusion which has increased in the\n interval. These findings are consistent with left lower lobe pneumonia. Note\n that part of the right hemithorax is not included in this examination.\n\n IMPRESSION:\n 1. Right lower lobe pneumonia. There is increase in the left pleural\n effusion.\n 2. Volume loss in the right lung with deviation of the mediastinum and heart\n to the right side and right pleural effusions are unchanged compared to the\n previous study. There is no evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823488, "text": " 6:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 75 y/o male with lung cancer and evaluate for interval change.\n\n PORTABLE AP CHEST: Comparison is made to previous films from .\n\n FINDINGS: The chest radiograph is unchanged when compared to the previous\n study. The ET tube, right IJ central line, and ICD device remain in unchanged\n position. Again noted is right sided chest tube. No obvious pneumothorax.\n Enlarged right pleural effusion. Unchanged appearance of the right hilar\n opacity. There is unchanged appearance of the patchy opacities in the left\n lung and left pleural effusion. There is no evidence of pneumothorax. The NG\n tube is located in the stomach.\n\n IMPRESSION:\n\n Unchanged appearance of the chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-07 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 823202, "text": " 12:58 PM\n BILAT UP EXT VEINS US Clip # \n Reason: PT WITH BILAT UE SWELLING, R/O CLOT\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with bilateral UE swelling (L>R) w/ h/o afib, previously on\n coumadin\n REASON FOR THIS EXAMINATION:\n r/o clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral upper extremity swelling, left greater than right, with\n history of atrial fibrillation.\n\n COMPARISON: None.\n\n FINDINGS: -scale, color, and Doppler son of the left internal\n jugular, both subclavian, both axillary, both brachial, both basilic, and both\n cephalic veins were performed. The right internal jugular vein was not imaged\n secondary to overlying tubing and bandages. Normal wave forms,\n compressibility, color flow, and augmentation were demonstrated in all these\n vessels. No intraluminal thrombus was identified.\n\n IMPRESSION: Limited evaluation as the right internal jugular vein was not\n imaged. No evidence of deep venous thrombus in either upper extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 823299, "text": " 9:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia in left lung\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia in left lung\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 year old man with lung cancer and right pleural effusion.\n\n COMPARISON: previous day.\n\n AP SINGLE VIEW OF THE CHEST: The ET tube, the right IJ central line and the\n left chest wall pacemaker and its wire are in good and unchanged position.\n There is a right-sided chest tube. There is a small residual\n hydropneumothorax. There is continued shift of the heart and mediastinum to\n the right side. There is again evidence of collapse/consolidation of the\n underlying right upper lobe and some patchy bibasilar infiltrates are noted in\n the lower lobes. There is also a small left pleural effusion on the left\n side. There is unchanged appearance of cardiac enlargement (mainly left\n ventricular).\n\n IMPRESSION: Unchanged appearance of the chest in the interval.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 824023, "text": " 8:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for reexpansion post bronch for pulm toilet followi\n Admitting Diagnosis: LUNG CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with lung ca and right pleural effusion, intubated\n getting photodynamic therapy\n REASON FOR THIS EXAMINATION:\n evaluate for reexpansion post bronch for pulm toilet following photodyn tx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung cancer and right pleural effusion, status post bronchoscopy.\n\n COMPARISON: .\n\n FINDINGS: AP portable semiupright view. The endotracheal tube terminates at\n the thoracic inlet. The nasogastric tube remains in unchanged position. The\n right internal jugular venous catheter terminates in the mid SVC. The single\n pacmeaker lead remains in stable position. A chest tube is again noted at the\n right apex. The previously described loculated right pleural effusion with a\n loculated hydropneumothorax component appears unchanged. No improvement in\n aeration of the right lung is identified. There is stable amount of\n mediastinal shift to the right. There is also a posteriorly layering left\n pleural effusion, unchanged since the prior study.\n\n IMPRESSION:\n 1. Stable appearance of right hydropneumothorax, without improvement in right\n lung aeration.\n 2. Stable left pleural effusion.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-17 00:00:00.000", "description": "Report", "row_id": 1602471, "text": "Micu Nursing Progress Note:\n\nNeuro: sedation increased to prior levels at start of shift. Required several boluses during long aline attempt procedures. Neo briefly increased in respnse to hypotension d/t sedation. Pt in obvious pain with all nursing care. Opening eyes to pain only. Moving upper extremeties. Fentanyl and versed gtt continue.\n\nCV: required increase neo gtt, but later titrated to same dose as at start of shift to maintain map >60. vasopressin gtt remains on. Tmax 99.4. HR 79-98 afib with frequent ectopy. hct, plts trending down.\nCT conts to require frequent dsg changes d/t fluid leaking at site. measurable outpt 300cc for shift.\nUnable to place aline. Multiple attempts made.\n\nResp: Rec'd on PSV 15/peep 10. No abg obtained. mixed venous 42/44/7.27. MD's aware. no changes made. TV's 500-650. rr 12-30. Minimal secretions.\n\nGI/GU: tf's at 30cc/h, tolerating without difficulty. No stool this shift. Insulin gtt titrated 2-4u/h. Bun/creat increased from yesterday. U/O ~5-10cc/h\n\nInteg: CT, scrotum, and all old puncture leaking copious amts of serous fluid. Douderms x 2 to back and sacral area intact.\n\nsocial: wife and dtr into visit for several hours and then later called.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-17 00:00:00.000", "description": "Report", "row_id": 1602472, "text": "Respiratory Care:\nPatient remains on ventilatory support (CPAP/PSV) with no changes made throughout the night.\n\nNo abg drawn and no RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-17 00:00:00.000", "description": "Report", "row_id": 1602473, "text": "Nursing Progress Note\nFamily meeting held today. discussed pt's grave pronosis and medical team reaching the limits of treatment options. discussed CMO. family continues to have much difficulty making that decision, requesting that treatment continue as it currently is, including IV abx's pressors. ethics and social work involved. Pt's condition unchanged. Neosynephrine at 2 mcg/kg/min and Vasopressin at 0.04units/hr. fentanyl increased from 50 to 100mcg/hr and Versed also increased to 2 mg/hr w/ the primary nursing goal of maintaining patient's comfort.\n\nROS-\n\nCV- Afib HR 70-90's. unable to replace Aline. NiBP 90-110's systolic w/ MAP's 60-70. extremities cool, especially L hand, fingers cyanotic. unable to palpate or dopplar radial pulses. pressors as mentioned above.\n\nRESP- vent changed from PSV back fo AC 14X600/7/50%. unable to check abg's. o2 sats 93-100%. suctioning necrotic tissues from ETT. CT remains to 10cm suction w/ approx 150cc out this shift. LS very coarse, diminished at R base.\n\nNEURO- sedation as above. very active and uncomfortable in bed when more lightly sedated. grimaces when turned or moved. moving UE's.\n\nSKIN- extreme anasarca. oozing copious amounts serosanguinous fluid from every break in skin integrity. both lower arms saturating pads q2-3 hrs. CT site oozing, dressing changed X2. skin tears to R chest. stage 2 decub w/ eschar to coccyx, duoderm changed. scrotum very edematous and oozing.\n\nID- yeast present in blood, sputum and catheter tip. further BC's pending. afebrile w/ wbc count 22.8. remains on multiple PO and IV abx.\n\nGI/GU- TF's remain at 50cc/hr, not advanced d/t poor bowel sounds. abd slightly distended, hypoactive to absent bowel sounds. no stool. foley draining scant u/o, approx 5-7cc/hr. crt and BUN rising. remains on insulin gtt, unchanged all shift at 4.5 units/hr. approx 39 liters positive (not accounting for fluid lost through skin oozing)\n\n wife and daughter and many other family members here to visit. family meeting. updated on progress this afternoon.\n\nPLAN- primary goal: patient's comfort.. increase fentanyl as appropriate. titrate up vasopressors w/ goal MAP's >65. avoid sticks or painful events. monitor TF residuals. continue IV abx's. plan is not to add any new vasopressors, titrate up neo if BP drops.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-17 00:00:00.000", "description": "Report", "row_id": 1602474, "text": "Patient remains on mechanical ventilation hard to draw ABG arm filled with serous fluid. CMO on Atrovent Q4 suctioned PRN for bloody sputum will continue to follow\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1602478, "text": "NPN 7p-7a\n\nneuro: pt unresponsive to stimuli/pain, continues on 100mcg/hr fentanyl and 2mg/hr versed gtt for pain management\n\ncv: HR 70-80's, Afib with multiple PVC's, NBP 80-100's/'s with MAP's 35-67, pt continues on Vasopressin and Neo gtt's, pulses absent and extremeties cold to the touch and dusky, +anasarca and pt body continuously weeping serous fluid, positive >40Litres (without accounting for fluid lost through skin), am labs pending\n\nresp: RR 14-15, Sats 96-99, LS coarse through out, pt continues on AC 14x600/10/50%, CT continues to drain light straw colored liquid to LWCS\n\ngi: pt tolerating tube feeds at 50cc/hr with residuals ~10cc q4hr, continue with insulin gtt, no BS/flatus, no stool this shift, abd obese/distended/soft/does not appear tender\n\ngu: u/o 0-7cc's, pt goes several hours at a time without making urine, urine dark yellow and appears clear\n\ninteg: skin is cold/dusky BUE and cold/pale BLE and consistently clammy; area surrounding CT dressing is reddedend and draining serous fluid from skin tears; serous fluid draining around the foley; stage II on coccyx covered with duoderm\n\nID: Tmax 96.1, continue with fluconazole ( bld and sputum cx +yeast),\n\nsocial: daughter, wife and cousin returned in the evening for a few hours and will be back in am.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1602479, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc, maintaining spo2 96%; bs coarse, sxn thick blood tinged secretions, rx with mdi atrovent, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1602480, "text": "Resp care\nremains intub/full ventilatory support in ac mode. no changes except fio2 incr to 100% during hemodynamic instability. no attempts at weaning indicated.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 1602481, "text": "NPN 7a-7p\nEvents: 1630, HR dropped to 50 c widened qrs and peaked T waves.\n\nNeuro: Unresponsive to all stimuli. Continued on same doses of Fentanyl and Versed, but d/c Versed at 1645.\n\nCV: Pt in A-fib most of day c HR 78-85 c PVCs. At 1630, noted HR at 50 as above. At same time, BP 88/20, and desating to 88. EKG taken, in 1st deg AV block, paced. Dextrose 50% 1 amp, Insulin 10uReg, Bicarb 1amp, Calcium Gluc 1 amp given. Labs sent. Some improvement in HR, BP and sat. K back at 6.9, Na 124, Co2 11. Repeat of same meds at 1805. To repeat labs at .\n\nResp: AC 600x14, FIo2 50% til 1630, up to 100%, peep 10. o2 sat improved from 88 to 92-97%. Pt appears to have agonal breathing, occ extra shallow resp, RR 14-20. coarse BS throughout.\n\nGI: TF d/c'd due to extremely high residuals >400. BS absent, distended abd. Insulin drip d/c this am, qid FS.\n\nGU: 0-2mls/hr uo, amber, clear. Creat cont to increase -4.4.\n\nSkin: All extremeties cold. Absent pulses. Anasarca. Temp 95.5. Warming blanket applied. Coccyxgeal stage 2 wound covered c duederm.\n\nSocial: Wife and daughter visiting. Frequent discussions with MDs regarding stopping treatment. Family coming to understanding of futility of treatment.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-08 00:00:00.000", "description": "Report", "row_id": 1602433, "text": "NPN 1900-0700:\n\nNEURO: NO change in Fentanyl or Versed gtt rates. Pt opens eyes to voice, follows simple commands, MAE, PERRL. No episodes of agitation.\nRESP: Able to titrate FiO2 down to current level of 40%; no other vent changes made. Pt has increasing metabiloc acidosis, partially complensated. Most recent serum CO2 14; most recent ABG: 7.34/29/82/16/-8. LS rhonchorous t/o. Early in shift minimal secretions; after MN suctioned multiple times for thick white secretions.\nC-V: Early in shift required increase in Neo dose; later able to wean back to 1.29mcg/kg/min after pt recieved total of 2.5L in boluses. HR 70's, NSR with frequent PVC and runs of ventricular bigeminy. Ca repleted with total of 5 amps Ca Glu; most recent Ion Ca 1.16. Mg and K are low-normal.\nID: Afebrile, WBC up to 1.0. BC X 2, urine cx sent; pt empirically started on Vanco and cont's on Ceftaz.\nGI: TF's advanced to 20cc/hr with no residuals and run till MN when they were stopped in anticipation of PDT today. Belly benign; small BM X 2.\nGU: U/O generally ~30cc/hr; BUN/creat down a bit to 49/1.3.\nHEME: Hct 28.7 (down from 31.4) in setting of multiple fluid boluses. Plt 85 (up from 81); INR 1.6 (up from 1.2). Stool OB-; no obvious source of blood loss.\nENDO: FSBS up to >200; insulin gtt initiated and has been increased several times, but BS still >200 at this time.\nSOCIAL: dtr in with other family members; asking appropriate questions, support provided. They seem very realistic.\n\nA: remains very ill\n\nP: medicate as needed for comfort; wean vent as able; pulmonary hygeine; titrate Neo prn for MAP >60; ? further fluid boluses; follow serum bicarb and ABG's; anticipate restart TF's after procedure; follow U/O; monitor for evidence of bleeding; titrate insulin gtt prn; abx as ordered; follow WBC and cx results; support family.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-08 00:00:00.000", "description": "Report", "row_id": 1602434, "text": "Resp Care Note: Pt remains intubated via 8.0mm ETT secured 21cm @ teeth. BS coarse t/o. MDI given as ordered. No vent changes made this shift. ABGs show partially compensated metabolic acidosis. Please see Carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-08 00:00:00.000", "description": "Report", "row_id": 1602435, "text": "ALTERED RESP STATUS\nD: NEURO: PT EFFECTIVELY SEDATED ON VERSED GTT AT 0.5 MG/HR AND FENTANYL GTT AT 25MCG/HR. PT DOES OPEN EYES TO VERBAL STIMULI AND\nDOES RESIST WITH TURNING. MAE'S PURPOSEFULLY. PT HAS NOT REQUIRED ANY ADDITIONAL SEDATION.\n\nRESP: REMAINS ORALLY INTUBATED ON VENT SETTINGS OF 40%/600/AC 14 WITH 10 PEEP AND O2 SATS> 95%. COARSE BS BIL ON AUSCULTATION AND ETT SUCTIONED X3 FOR THICK TAN SPUTUM . PT A TOTAL OF 150 MG OF PORFIMER SODIUM AS A PHOTODYNAMIC THERAPY AND PT'S ENVIRONMENT IS TO REMAIN DARK. PT IS PHOTOSENSITIVE. NEED TO KEEP ROOM BLOCKED FROM SUNLIGHT AND ONLY INTERMITTENT LOW ROOM LIGHT. PT HAVE BRONCHOSCOPY AT THE BEDSIDE IN THE AM BY PULMONARY INTERVENTIONALIST.R CT REMAINS TO WATER SEAL WITH POS FLUCTUATION NOTED AND LG AMT OF SEROUS DRAIANAGE.\n\nCV: HAVE BEEN ABLE TO WEAN NEO GTT TO 0.54MCG/KG/MIN TO KEEP MAP>60. HR 70-80'S WITH FREQ PVC'S AND OCCASIONAL VENT BIGEMINY.K+3.9 WAS REPLETED WITH 20 MEQ KCL IVPB AND FOR A MG OF 1.9 PT ALSO RECEIVED 1 GM MG. WILL FOLLOW ELECTROLYTES AS ORDERED AND REPLETE AS NEEDED.\n\n\nGI: OGT IN GOOD POSITON BY AUSCULTYATION AND PROBALANCE TUBE FDGS RESTARTED THSI AFTERNOON AT 20 CC'S/HR AND WILL INCREASE AS PT TO A GOAL RATE OF 65CC'S/HR. MINIMAL RESIDUALS NOTED. ABD SOFT AND NONTENDER WITH POS BOWEL SOUNDS ON AUSCULTATION AND PT HAS BEEN INOCONTINENT X 3 FOR LG MATS OF SOFT BROWN STOOL THAT IS GUIAC NEG. HCT STABLE AT 28.7. PLAN IS TO KEEP PT NPO AFTER MIDNOC FOR POSSIBLE BRONCHOSCOPY AND ACTIVATION OF THE PDT BY BRONCHOSCOPY . VBECAUSE OF INCREASED STOOL OUTPUT NEED TO RECONSULT DIETICIAN FOR DIFFERENT RECOMMENDATIONS FOR TUBE FDGS.\n\nGU: HOURLY UO HAS INCREASED TODAY TO > 30CC'S/HR. BUN DOWN TO 49 AND CREAT AT 1.3. I&O POS FOR 2 L FOR 24 HRS AND 11L POS FOR LOS. WILL FOLLOW CLOSELY AND IF UO DROPS OFF PT NEED ADDITIONAL FLUID BOLUSES OF NS. PT HAS 2+ EDEMA TO ALL EXTREMITIES.\n\nID: CONTINUES TO RECEIVE CEFTAZIDINE AND VANCOMYCIN FOR PRESUMED PNEUMONIA. PT REMAINS AFEBRILE. FOLLOW FEVER CURVES AND AWAIT FINAL CULTURE RESULTS.\n\nSOCIAL: PT REMAINS AND PT'S DAUGHTER AND WIFE WERE IN TO VISIT THIS AFTERNOON AND WERE UPDATED BY DR. . CONTINUE WITH PRESENT MEDICAL TX AND KEEP FAMILY INFORMED ON DAILY BASIS AND OFFER EMOTIONAL SUPPORT TO THEM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-09 00:00:00.000", "description": "Report", "row_id": 1602436, "text": "Micu Nursing Progress Note:\n\nCV: required increase in Neo gtt to maintain SBP >90 and map >60, despite 500cc fb x 2. Neo increase to 1.29 mcg/kg/min and then able to wean to .86 mcg/kg/min. Extrem cool, pale. Hct stable. ICa++ 1.07 repleted w/ 2grams. Plts still low at 82 and wbc increased to 7.9(double checked by Lab). Tmax 97.8.\n\nResp: status stable overnight unitl this am when patient became agitated and tachypnic to 30's. Pt denied SOB but O2 sat 88%(via oximeter on earlobe). ABG sent -> 53/27/7.36, with O2sat 88. FiO2 increased to 50%, rec'd versed bolus->next abg improved. LS coarse. +++secretions -yellow thick.\n\nGI/GU: TF's off at midnight for bronch this am. Attempted to start D51/2ns at 100cc/h to prevent bs from decreasing. FSBS increased and required insulin gtt to be restarted. D51/2 NS d/c'd. Stool x 1-> mushroom cath placed, drng brown liquid stool. u/o 20-40cc/h. +12L for LOS. + 2100cc at midnight.\n\nNeuro: photosentivity and neutropenic precautions enforced. Able to move all extremeties. apppears to answer questions appropriately. Fentanyl and versed gtt continue.\n\nSocial: family into visit last evening.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-11 00:00:00.000", "description": "Report", "row_id": 1602448, "text": "pmicu npn 7p-7a\n\n\n events overnoc include successful weaning of the vasopressin. also, the pt's uop has been negligable at times. the team was made aware and the pt received a single 500cc ns bolus w/o improvement in his uop. additionally, ett advanced to 24cm at the lip after the pt developed a significant cuff leak despite efforts to reinflate the balloon.\n\nreview of systems\n\nrespiratory-> pt remains intubated and vented on ac 14x600 w/peep10 and o2 40%. srr 3-7/min. pt was suctioned minimally until he was repositioned ~4am. the pt subsequently developed the cuff leak and became bronchospastic. she has required frequent suctioning since then for moderate amts of thick, yellow sputum. repeat abg on current settings: 7.33/26/66/14/-10.\n\ncardiac-> hr 70-90's, sr w/episodes of ventricular and atrial bigemeny. sbp 110-130's off of vasopressin. cvp readings overnoc.\n\nneuro-> easily arousable to stimulation but consistently not following commands. remains on a versed and fentanyl qtts w/no change in qtt rates although the pt was bolused several times w/both.\n\ngi-> abd is soft, nontender w/+bs. tube feedings increased to 40cc/hr w/o complication. remains on flagyl for c. diff.\n\ngu-> poor uop despite improved hemodynamics. pt appears to be prerenal w/rising bun/creat.\n\nendo-> remains on an insulin qtt @2u/hr and maintaining fs between 100-130.\n\naccess-> right quad lumen ij and right radial a-line are patent and intact.\n\nsocial-> pt's wife and dtr were in to visit last evening. both were updated on the pt's condition. no calls overnoc.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-11 00:00:00.000", "description": "Report", "row_id": 1602449, "text": "Nursing Progress Note\nPt remains off vasopressor support. SBP 110-130's systolic. hemodynamically stable. bronched at bedside today and large amount of necrotic tumor tissue removed.\n\nROS-\n\nCV- NSR w/ frequent multifocal PVC'and Ventricular bigeminy. BP as mentioned above. extmeites cool anasarca w/ + pitting edema all around body. very prominent scrotal edema. oozing serous fluid from multiple sites, including scrotum and R hand. hct stable, platelets trending downward at 47.\n\nRESP- fio2 increased to 50% after am abg was 7.33/26/66. repeat abg on 50%= 7.32/28/131. o2 sats 96-100%, difficult to obtain reliable pleth at times. LS continue to be coarse. thick yellow secretions. R CT in place, continuing to ooze large amount of serous fluid from CT site, team aware. CT to 10cm suction, + crepitus - respiratory variations in CT. Per Dr. , R mainstem now open up to RLL.\n\nNEURO- remains sedated on 0.5mg/hr versed and 0.25mcg/hr fentantyl. nods head yes/no but not squeezing hands or following other commands. denies pain. remains on photosensitive precautions for photodynamic therapy.\n\nGI-GU- TF's, probalance, recently advanced to goal rate of 65cc/hr. small residuals <25cc. abd soft. Mushroom catheter in placed, draining liquid brown, CDiff + stool. foley draining very poor amount dark yellow urine, appro 2.5-15cc/hr. team aware. pt is 22 liters positive since MICU admission. remains on insulin gtt at 203 units/hr.\n\nSKIN- stage 2 decub to coccyx. duoderm removed, DSD placed. skin thin, tears easily, oozing.\n\nID- contact . remains on IV ceftaz and po Flagyl. afebrile but WBC's rising, currently 22, was 1.1 on admission.\n\nSOCIAL- daughter and wife in to see, very supportive. updated in progress/ plan.\n\nPLAN- rebronch tomarrow and sunday to continue w/ phtodynamic therapy debridement of R mainstem tumors. monitor BP and U/O. will need diuresis when BP remains stable. also monitor CT site and change dressings as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-11 00:00:00.000", "description": "Report", "row_id": 1602450, "text": "Resp CAre\nremains intub/vented in ac mode. incr fio2 today, otherwise no change. bronch by IP. sxned for scant amts of secretions. pip/plat wnl. atrovent given q4h. c/w vent support, daily bronchs.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-12 00:00:00.000", "description": "Report", "row_id": 1602451, "text": "FULL CODE Contact Precautions (c-dif) NKDA\n\n\nNeuro: Fent gtt at 25mcg/hr and Versed .5mg/hr w/ good sedation. Opens eyes and moves extrems to stim - nursing care, but does not nod to questions.\n\nCV: HR=70s, NSR w/ freq PVCs/bigeminy. BP=100-120/50s. Weak periph pulses, extrems warm, +generalized edema. R CT intact w/ small amt straw fluid. CT dressing dry/intact. It was saturating on previous shift requiring freq dressing changes, but it has been dry. Neg air leak/crepitus. CVP 7-9\n\nResp: AC 16x600, 50%, P=5. Lungs clear except R base - crackles. Sx small amt thick tan secretions via ETT. ABG unchanged from previous gases.\n\nGI/GU: Abd soft, hypo BS, no BM. Mushroom cath in place. TF Probalance at 65cc/hr (goal), tol ok w/ min resids. Foley cath w/ marginal u/o (15-20cc/hr)- no change from last 24 hrs. Currently +500 cc for shift and 24L overall.\n\nSkin: coccyx red, DSD in place. CT site and dressing on R hand dry (had been oozing serous fluid in past shift). Generalized edema.\n\nID: afebrile. On ceftaz and flagyl\n\nAccess: R rad a-line, RIJ quad lumen.\n\nLabs pending. Insulin gtt at 3 units/hr and checking FS q2hr w/ range of 128-140.\n\nSocial: Wife called earlier in shift and updated on pt's status.\n\nPlan: Bronch again today. Monitor cardiac/resp/neuro status. Assess labs - repleat lytes prn. Maintain fent and versed gtts for comfort. Update family.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-06 00:00:00.000", "description": "Report", "row_id": 1602427, "text": "Please refer to Nursing admission history for events leading up to admission.\n Pt is a 75 y/o male admitted for rigid bronch/stent placement for R lung mass. Pt had been stable at , but upon arrival to MICU, pt hypotensive to 60's/20's--after 1.5 L fluid, BP somewhat improved to 90's/40's. Plan to establish central access and use pressors if necessary. Dtr on her way in to hospital. Pt is currently a full code.\n\n Neuro: Pt alert and able to nod appropriately to questions. Calm. Able to move all extremities strongly and to command. 2 mg IV versed prior to line placement per Dr. .\n\n CV: Afebrile. Pt in ? NSR--pt having very frequent ventricular ectopy and rhythm appears irregular at times, p-waves discernable. EKG attempts unsuccessful due to artifact--will attempt another EKG after line placement. BP 60's-70's, pt mentating, UOP low--2nd liter bolus infusing now. Aline pressure currently 99/41 (58). Full set labs pending. Clot current in BB. Pt also has 1 # 20 PIV.\n\n Pulm: Pt vented on AC 14/600/60%/5 with RR 14, sats in mid 90's. Lung sounds incredibly rhoncherous despite numerous suction passes. Pt suctioned for huge amts pink creamy sputum with streaks of blood. R CT to 20 cm SXN draining large amts straw colored fluid (200 cc since 3pm).\n\n GI: OGT + plcmt via air bolus but cxr needs to be done to confirm placement. + BS, no stool X 3 days per RN, non tender.\n\n GU: FOley to gravity. Small amts amber urine with sediment. UOP very low with hypotension.\n\n Skin: Pt has stage II decub on coccyx approx 3 cm round--duoderm applied. Heels sl. reddened.\n\n Family: awaiting dtr's arrival.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-15 00:00:00.000", "description": "Report", "row_id": 1602464, "text": "Micu Nursing Progress Note:\n\nNeuro: agitated, flailing arms in bed, increased rr and apparent discomfort with any nursing care. Fentanyl and versed gtt's increased for comfort with excellent effect.\n\nResp: no changes made to vent settings -rec'd and cont's on a/c 600x14 peep 7 fiO2 50%. Pip's decreased slightly = better compliance. Attempted to sx several times both with inline cath and reg sx cath. No cough response noted and no secretions obtained. Resp aware. ABG consistent with prior--7.33/24/73.\n\nCV: Able to titrated Neo gtt down- now 1.29 mcg/kg/min. Also continues on vasopressin. Will cont to titrate neo gtt as needed to maintain MAP >60. HR 70-90's afib with ++pvc's. CVP 7-12. No fluid bolus given. Central line re-sutured, dsg changed. CT with incorrect cmH2O--pleuravac changed to 10cm as ordered. Drng serous fluid, and leaking fluid through dsg- dsg changed x 2.\n\nID/labs: tmax 98.3. Abx regimen-flagyl for c-diff, cipro, vanco, and ceftazidime for mrsa/?sepsis. WBC increased to 27.0. dexamethasone discontinued -> no adrenal insufficiency. alk phos elevated slightly. Plts decreased, and appears to be in dic. lactate slightly elevated. Inr elevated as well.\n\nGI/endo/GU: tf's cont with no residuals. No stool overnight. Insulin gtt increased currently 5.0 u/h, FS q1hr. U/O 10-25cc/h. + 2L at midnight and 34L LOS.\n\nSkin: Breakdown noted around edges of CT dsg. Hands and arms leaking fluid bilaterally. Fluid leaking from scrotum. Scrotum edematous and painful. Duoderms in place- one on upper back and one on sacral area.\n\nSocial: wife and dtr in most of evening. Dtr left after talking with friends. appeared very distraught. Is to meet with DR today at 10:30.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-15 00:00:00.000", "description": "Report", "row_id": 1602465, "text": "NPN 7a-7p\n\n Pt. made CPR not medically indicated during family meeting with Dr. . BC + for yeast started on ambisome. Subsequently, line placed on left side IJ, Right side to be pulled after CXR confirms placement.\n\nReview of Systems-\n\n Pt. remains on Fentanyl 50mcg and Versed 2mg with bolus sedation need for line placement and nursing care X 1. Pt. found to be thrashing arms about this am calmed with verbal assurance. Pt. appears to be well sedate when left alone.\n\nResp- No vent changes made today given metabolic acidosis. Pt. remains on A/C 600X14 50% PEEP 5 with sat's 92-95%. Sx'd q 4 for minimal to no secretions. Overbreathing ventilator by about 4-5 bpm. LS- clear, diminished on right base. CT to 10cm sx and appears to be draining 100-200cc/ shift of serous fluid. Dsg. changed X 1. pt. will remain on A/C no vent changes overnoc.\n\n Pt. remains on vasopressin at 0.04u/min and Neosynephrine. Neo was off this am for short time, now on to keep MAP >65 (goal). CVP read as >9 this am range 11-13. No IVF bolusing given today. 2amps of bicarb given for metabolic acidosis. 10mg of Vit. K also given for coagulopathy X 1. Pt. remains with generalized anasarca given low albumin and weeping of serous fluid. Extremeties remain cool and edemedous. Skin impaired, duoderms on coccyx and back side for abraded areas.\n\nEndo- requiring 2u IV insulin all shift, FS checked q1-2 hours\n\nGI- ABD soft/ distended. Absent BS at start of shift. TF held d/t high residuals at 8am (100cc) X 1 hour. Restarted at 30cc/hr and increased to 40cc/hr with no issues. No stool, softeners given.\n\nGU- U/O 10-15cc/hr amber with sediment. Low u/o thought to be related to ATN s/p hypotension.\n\n Pt. remains on Vanco, ceftriazidime, cipro, flagyl and started on ambisome today for fungemia. Line tip of other IJ to be cultured.\n\nSocial- Dtr. and wife had family meeting today with Dr. , plan is no withdrawal of current supportive measures. However, made CPR/ code not indicated given poor prognosis. + MRSA sputum, c.diff\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-15 00:00:00.000", "description": "Report", "row_id": 1602466, "text": "Resp Care\n\nPt remains vent support with no changes. Suctioning minimal secretions. BS clear. No plan for weaning at this time\n" }, { "category": "Nursing/other", "chartdate": "2200-04-16 00:00:00.000", "description": "Report", "row_id": 1602467, "text": "Micu Nursing Progress Note:\n\nNeuro: appears comfortable until moved. Requires bolus on fentanyl to provide comfort with nursing care. Able to move upper extremeties. Not responding as readily to voice.\n\nCV: remains in afib with rate 70-100, pvcs frequent. am elctrolytes pending. Required increase in Neo dose to maintain MAP's > 60-65. Continues on vasopressin dose. Rec'd 3 amps bicarb d/t persistent metabolic acidosis. lactic acid 1.6. CT dsg changed. CT site continues to leak serous fluid in large amts.\n\nID: slightly hypothermic. ambisome started. BC x 2 + fungal isolater drawn. New central line placed. ? whether aline should be changed --aline was new site on . all other abx's continue as ordered.\n\nResp: vent settings unchanged. a/c 600x14 fio2 50%, srr 0-4, minimal secretions. am abg 100/29/7.33 consistent with prior abgs.\n\nGI/GU: continues to require increased insulin gtt dose -currently at 8u/hr. Tf's not yet at goal -will advance slowly. u/o poor 10-25cc/h. 1500cc positive at midnight and 35.6 L postiive for LOS\n\nskin: total body anascarca. Leaking bilat upper extremeties, scrotum and at all iv/line sites. duoderm uppper back and sacral area intact.\n\nSocial: dtr and wife into visit last night. dtr requiring much reassureance and support. Visibly distressed. Called later in the evening.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-07 00:00:00.000", "description": "Report", "row_id": 1602428, "text": "\nPt maintained on a/c ventilation at 80% with marginal oxygenation and an alkalosis accomplished by a minute ventilation of 17liters, with a very irregular pattern of respiration. Meds given, sx for lrg amts of bloody secretions. Pt sedated with systolic of 112. Pt is to be seen by Int. Pulm. tomorrow for rigid bronch. and stenting if possible. Plan is to keep pt comfortable and stable. Increased peep to 10cm, spoke to nurse about PCV ventilation if no improvement in gas exchange, all in agreed it would be worth a clinical trial.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-09 00:00:00.000", "description": "Report", "row_id": 1602437, "text": "Respiratory Care:\nPatient's SPO2 dropped dramatically, and the PO2 was confirmed to hypoxic levels. FIO2 increased to 50%, with excellent rebound of PO2.\n\n\nNo RSBI due to level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-09 00:00:00.000", "description": "Report", "row_id": 1602438, "text": "Resp Care Note.\n\nPt remains on A/C ventilation. He is on neutropenic precautions and is very light sensitive. Medical plan is to incr fluid to raise cvp. Currently pt is on 10 peep,50%,600x 14\n" }, { "category": "Nursing/other", "chartdate": "2200-04-09 00:00:00.000", "description": "Report", "row_id": 1602439, "text": "Nursing Progress Note\nPt remains on neosynephrine. titrated up to 2 mcg/kg/min, currently at 1.5 mcg/kg/min. Vasopressin added as neo was being titrated upward. Pt has recieved 4 liters in NS boluses today, d/t low CVP's, w/ minimal effect on CVP. continues to have poor urine output. Pt into afib this am, self-converted around 1400 today after vasopressin started. photodynamic therapy unable to be activated today. will plan on bronch tomarrow to activate medication.\n\nROS-\n\nCV- currently in NSR w/ frequent PVC's and bigeminy. HR 80-130's, higher when in Afib. extremities cool and edematous. CVP 6-8 throughout shift.\n\nRESP- no vent changes made. remains on AC 600X14/10/50%. LS generally clear at start of shift, increasingly coarse w/ pleural rub later in shift. R CT in place, drainage chamber changed after it accidently tipped over, altering output count. O2 sats 96-100% throughout shift. CT site w/ crepitus, oozing slightly. L lobe pna worsening.\n\nNEURO- remains sedated on 0.25mcg/hr fentanyl and 0.5 mg/hr fentanyl. arousable to stimulus. MAE. follows commands at times. Photosensitivity precautions enforced.\n\nGI- TF's to be restarted. OGT for meds/ TF's. Mushroom cath in place, draining liquid tan stool. as of this writing, pt is approxiamtely 5.5 liters positive for the day, 17 ltiers positive since admission to MICU.\n\nGU- foley draining poor amount amber colored urine, approx 5-15cc/hr before boluses, 20-30cc/hr after boluses.\n\nSKIN- sacrum reddened. duoderm intact.\n\nID- started on PO cipro for ?pseudomonas. remains on ceftaz and vanco.\n\nSOCIAL- daughter and wife here to visit, updated on progess/plan\n\nACCESS- R IJ patent, R aline.\n\nPLAN- unknown etiology for suspected sepsis. photodynamic therapy tomarrow at bedside. goal CVP 12. titrate pressors accordingly. please check vanco trough levels prior to midnight dose.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602440, "text": "Respiratory Care:\nPatient was able to tolerate a decrease to 40% on the FIO2. ABG results demonstrated an adequate oxygenation level.\n\nNo RSBI done due to the current level of PEEP required at this time.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602441, "text": "Respiratory Care:\nVent circuit changed to active humidification system in an attempt to mobilize the patient's secretions.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-18 00:00:00.000", "description": "Report", "row_id": 1602475, "text": "NPN 7p-7a\n\nevents: neo maxed out overnoc, da and spouse called and have remained bedside overnoc, no further pressors to be added but they do not want care withdrawn\n\nneuro: pt continues to be sedated on 100mcg/hr of Fentanyl & 2mg/hr of Versed, and rc'd a 50mcg bolus of Fentanyl while being repositioned, opens eyes/moves head/or lifts LUE in response to stimuli/pain\n\ncv: HR 70-90, Afib with multiple PVC's, NBP 80-110's/30-50's with MAP's 50-67 (goal >65) with Neo maxed overnoc at 4.28mcg/kg/min and Vasopressin at 0.04units/min, anasarca, BUE and BLE very cool, am labs pending\n\nresp: sats 97-99% on AC 14x600/10/50%, LC coarse with diminished bases, CT draining straw colored liquid, sxn'd for scant-copious amounts of tan-rusty thick sputum\n\ngi: tube feeds at 50cc/hr with residuals of 10cc's, abdomen soft & distended, +hypoactive BS, no stool this shift, continues on insulin gtt\n\ngu: u/o 3-7cc's/hr, amber and clear\n\ninteg: + anasrca, skin continuously weeping serous fluid, area surrounding CT dressing excoriated, duoderm on coccyx intact, abrasion from NBP on RUE ota and cuff rotated to LUE\n\nID: Tmax 98.4, WBC 25.6 (22.8), pt continues on flagyl, ciprofloxacin, ceftazidime and fluconazole\n\nSocial: Daughter, wife and sister in to visit after receiving a phone call from HO when MAP's began trending down, CPR is NI but family does not want to withdraw care\n" }, { "category": "Nursing/other", "chartdate": "2200-04-18 00:00:00.000", "description": "Report", "row_id": 1602476, "text": "Respiratory Care:\nPatient remains on ventilatory support with no changes made throughout the night. No morning abg.\n\nRSBI not performed due to the level of PEEP currently employed.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-18 00:00:00.000", "description": "Report", "row_id": 1602477, "text": "altered hemodynamics\nd: pt effectively sedated on fentanyl gtt at 100mcg/hr and versed gtt of 2mg/hr. can titrate as needed to keep pt comfortable. pt essentially unresponsive to verbal and painful stimulation. because of total anasarca pt did receive a bolus of 50 mgc icp fentanyl to assure that pt would not experience any discomfort with turning for back care. no spontaneous movements to extremties and did not check pupils because pt remains photosensitive s/p pdt.\n\nresp: pt orally intubated and vent settings unchanged-50%/600/ac 14 with 10 peep and o2 sats> 94%. lung sounds coarse bil and diminished at the bases. r ct to 20cm wall suction and neg leak-draining straw colored drainage.pt noted to have periods of agonal breathing. will continue with present support.\n\n\ncv: hr 80-90's with sbp 88-103. pt on maximum infusion rate of neo at 4.28mcg/kg/min and vasopressin at 0.04u/hr. will not add additional pressors. family is aware of this plan and aware that his prognosis is extremely grave.\n\ngi: ogt in place and receiving probalance tube fdgs at goal rate of 50cc's/hr. no stool output today and hypoactive bs auscultated to abd.\n\n\ngu: no uo for 12 hrs and pt now 43 liters pos for los. total body anasrca nad pt continuously oozing from his extremities and scrotum. >4+ pitting edema noted.\n\nsocial: pt is cpr not indicated. his family has gone home to get some rest and want to be called if his condition deteriorates . plan is to maintain pt comfort and titrate fentanyl and versed gtts as needed.will not add additional pressors. continue to keep family informed and offer emotional support to them.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-12 00:00:00.000", "description": "Report", "row_id": 1602452, "text": "Respiratory Care:\n\nPatient intubated on mechanical support. No changes in vent settings. Vt 600, A/C 14, Fio2 50%, and Peep 10. Pt. assisting 4-5 breaths. Bs coarse bilaterally. Atrovent MDI given Q4hr. L CT in place. Sx'd for sm amounts of thick yellow secretions. Abg reveal significant metabolic acidosis. ARF. S/P PDT. Plan to bronch later today. Continue with mechanical support and daily bronchs as needed.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-12 00:00:00.000", "description": "Report", "row_id": 1602453, "text": "MICU NPN 0700-:\n Pt had stable day, BP holding off vasopressors and no changes made to ventillator. Photosensitivity and universal precautions in place.\n\n Neuro: Pt continues sedated on 0.5 mg/hr versed and 25 mcg/hr fentanyl. He arouses to gentle stimuli and nods appropriately to questions. Pt consistantly follows commands, strength equal on both sides but limited secondary to debilitation/edema.\n\n CV: Hypothermic with tmax 96.5--blankets applied. Pt in NSR with frequent ectopy, runs bigeminy. BP stable in low 100's. K+ repleted this am with 40 meq KCL PO, Ca low but corrects to normal range. CVP running initially (goal to keep CVP up in setting of ? atn), now down sl. to 6-UOP currently good at about 20 cc/hr--plan to give 1 L NS bolus if UOP drops to < 10 cc/hr.\n\n Pulm: No vent changes. Pt remains on AC 16/600/50%5 with RR about 18. ABG good from nights. Lungs course with diminished R base. Pt suctioned q 3-4 hours for small amts brown sputum. Plan is for bronch in OR on Monday (NPO after midnight sunday).\n\n GI: Probalance infusing at 65 cc/hr via OGT. + plcmt via air bolus. Abd obese with hypoactive BS. No stool X 24 hours--mushroom catheter removed.\n\n GU: Foley to gravity. UOP 10-30 cc/hr. Urine is amber with some sediment.\n\n Endo: Pt on insulin gtt--titrated with protocol to keep BS 90-130. Currently gtt off for BS 90's.\n\n Family: Wife and dtr at bedside this afternoon--asking informed questions and appropriately concerned.\n\n Skin: Pt has mult skin tears on R arm--weeping copious amts serous fluid. DSD intact to coccyx. Duoderm intact to R flank. CT dressing CDI. Scrotum grossly swollen with skin fragile but intact--elevated with towels.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-06 00:00:00.000", "description": "Report", "row_id": 1602426, "text": "Respiratory Care:\n Patient arrived from . Intubated and ventilated for resp failure secondary to lung Ca of R mainstem bronchus. Plan for rigid bronch in OR tomorrow for eval. BS bilat with scattered rhonchi. Suctioned for med amount of thick, blood-tinged secretions. Plan to support overnight.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-07 00:00:00.000", "description": "Report", "row_id": 1602429, "text": "Micu Nursing Progress Note:\n\nCV: Borderline hypotensive all shift. CVP 4 and now 10 after rec-ing 4L NS. u/o fair to poor. u/o best with perfusion sbp >100. Sedation also contributing to hypotension but required for ventilation purposes. HR 70-80 with PVC's. Admission ekg with pacer spikes? and new L bundle? --> now cycling CK's. Extremeties cool and pale despite tmax 99.8. Corrected Ca++ 8.1. WBC now .5(had been 3.9) INR 1.2.\n\nResp: Desat-ing to 88--with abg revealing hypoxia. O2 increased, but still hypoxic. Peep increased to 8 and then to 10 with improved abg of 7.43/ 30/76. LS coarse. +++bloody secretions. CT to water seal. Draining lg amount serous fluid. DSG changed. + crepitus at site.\n\nNeuro: opens eyes to voice. answering questions appropriately. Requiring boluses of versed and fentanyl, but bp drops with sm amts. Will consider starting low dose pressor and contionous versed gtt to maintain better control.\n\nGI/GU: OGT clamped,minimal residuals. abd soft. No stool. Start stool regimen. u/o perfusion dependent with am creat 1.5. urine cx and osoms pending.\n\nSocial: family into visit -spoke at length with Dr. . #'s are on the board. Family members live close by.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-07 00:00:00.000", "description": "Report", "row_id": 1602430, "text": "ALTERED RESP STATUS\nD: RECEIVED PT SEDATED ON VERSED GTT AT 0.5 MG/HR AND AHVE TODAY ADDED FENTANYL GTT AT 25MCG/HR FOR ANLGESIC EFFECT. PT DOES OPEN EYES TO VERBAL STIMULI AND IS ABLE TO FOLLOW SIMPLE COMMANDS.DOES HAVE EPISODES OF TRASHING IN BED AND DOES NOD YES TO EXPERIENCING SOME ANXIETY BUT HAVE BEEN ABLE TO VERBALLY CALM PT DOWN. WILL TITRATE VERSED AND FENTANYL GTTS AS NEEDED.\n\nRESP: PT ORALLY INTUBATED AND VENTED WITH SETTINGS OF 80%/600/AC 14 WITH 10 CM PEEP AND O2 SATS> 94%. R CT TO WATER SEAL WITH POS FLUCTUATION AND DRAINING STRAW COLORED DRAINAGE. SEE CAREVIEW FOR ACTUAL TOTAL OUTPUT OF R CT. REPEAT BRONCH THIS AM SHOWED R ENDOBRONCH LESION COMPLETELY OBSTRUCTING R BRONCHUS INTERMEDIUS. . COARSE BS BIL ON ASUCULTATION. SUCTIONED ETT FOR THICK BLOODY TO TAN SPUTUM AND REPEAT SPUTUM FOR C& S SENT OFF.\n\nCV: PT AND PRESSOR DEPENDENT AT PRESENT. NEO GTT HAS BEEN AS HIGH AS 2.5 MCG/KG/HR TO KEEP MAP> 60. SINCE PT HAS R ECEIVED A TOTAL OF 3 L NS IN FLUID BOLUSES HAVE BEEN ABLE TO WEAN NEO GTT TO 1.5 MCG/KG/HR. WILL TITRATE NEO GTT AS NEEDED BUT WILL ATTEMPT TO TO OFF. IF MAP > 60 AND UO DROPS OFF WILL CONTINUE WITH IVF BOLUSES OF NS WHICH HE CAN RECEIVE 500CC'S Q 1-2 HRS PRN.\n\n\nGI: OGT IN PLACE AND IN GOOD POSITION BY AUSCULTATION. ABD SOFT AND NONTENDER WITH POS BOWEL SOUNDS ON AUSCULTATION. PT HAS BEEN STARTED ON PROBALANCE TUBE FDGS AT 10CC'S HR WITH GOAL RATE OF 65CC'S/HR. WILL FOLLOW RESIDUAL Q 4 HRS AND PLAN IS TOP HOLD TUBE FDGS AFTER MIDNOC FOR PLANNED PHOTODYNAMIC THERAPY IN THE AM.]\n\n\nGU: BUN=56 AND AND CREAT=1.5.PT WITH CONTINUES LOW UO AND RECEIVING 500CC NS BOLUSES AS NEEDED WITH NOTED INCREASE IN UO. PT HAS RECEIVED A TOTAL OF 3L OF IVF THIS SHIFT ALONE(TOTAL OF 7 LITERS SINCE TRANSFER TO ). IF MAP>60 AND UO LOW REPEAT FLUID BOLUSES BUT IF UO IS WNR AND MAP> 60 WEAN NEO GTT AS PT TOLERATES. FOLLOW FLUID STATUS CLOSELY.\n\n\nID: LOW GRADE TEMPS TODAY BUT PT NOW NEUTROPENIC WITH WBC=0.5. PT NOW STARTED ON CEFTAZIDINE 2 GM IVPB Q 12 HRS. WILL FOLLOW FEVER CURVES AND AWAIT THE RESULTS OF MICROBIOLOGY CULTURES SNET OFF.\n\nSOCIAL: PT IS A FULL CODE. DR AT BEDSIDE TODAY AND SPOKE WITH PT'S DAUGHTER REGARDING POOR PROGNOSIS. PT'S DAUGHTER STATES THAT HE WAS A \"GAMBLER\" AND WOULD WANT EVERYTHING ATTEMPTED . PLAN IS FOR PT TO UNDERGO PHOTODYNAMIC THERAPY IN THE AM . CONTINUE WITH PRESENT MEDICAL TX AND WEAN PRESSORS TO OFF AS TOLERATED. OFFER EMOTYIONAL SUPPORT TO FAMILY AND KEEP THEM INFORMED ON DAILY BASIS.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-07 00:00:00.000", "description": "Report", "row_id": 1602431, "text": "Resp Care\nPt remains on A/C-parameters noted. Plan was to go to the OR for a rigid bronchoscopy today. That was put on hold because pt too unstable. Pt had bedside bronchoscopy instead. Breath sounds are decreased bilat. Suction for a moderate amt of thick yellow. Atrovent MDI x 3. Will continue mech vent at this time.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-08 00:00:00.000", "description": "Report", "row_id": 1602432, "text": "Respiratory Care:\nBased on the abg results, the FIO2 has been titrated down to 40%. Patient still has a partially compensated metabolic acidemia.\n\nNo RSBI due to the level of PEEP currently required by the ptient.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602442, "text": "Micu Nursing Progress Note:\n\nCV: pressors, vasopressin and neo, rates unchanged. Dose maintaining sbp >90 and Map >60. FB LR 1000cc x 1 with minimal effect on bp and small transitory increase in u/o and cvp. HR 80's nsr with occassional bigem and multifoci. tmax 97.6. Vanco trough9.7. remains on cipro and ceftaz. Hct dropped from 30 to 26.1 will send new clot to bb. Plts also cont to trend down, now 66. MD called and informed of all pertinent lab values.\n\nResp: fiO2 decreased to 40%, otherwise vent settings unchanged. Tolerating decreased O2-> abg 86/29/7.32. Secretions mod white to blood tinged. CT outpt see i/o's. CT site with + crepitus. CT leaking through dsg. Dsg saturated. Dsg changed at 4am.\n\nGI/GU: remained npo overnight for possible procedure today. Mushroom cath patent and drng pungent brown liquid stool. BS covered via ssi.\nu/o 15-50cc/h. Bun/Creat holding at 54/1.5. ++19L los.\n\nNeuro: versed and fentanyl gtt rates unchanged. responds to voice and stimuli. MAE's\n\nSocial: dtr and wife in until evening. Dtr called during night for update.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602443, "text": "Adden to Resp Note:\n\n545PM Pt had potodynamic therapy via bronch earlier today, procedure waswithout complications. Suctioned frequently for small or mod secretions. Continuing on ac vent with 40%,600,14,10 peep\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602444, "text": "Adden to Resp Note:\n\n545PM Pt had potodynamic therapy via bronch earlier today, procedure waswithout complications. Suctioned frequently for small or mod secretions. Continuing on ac vent with 40%,600,14,10 peep\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602445, "text": "Respiratory Care Note\n\nB/S are considerably more noisy than yesterday, there are rales on I+E as well as some rhonchi on exp. Chest tube site is leaking baadly and may need replacement today. Pt is scheduled for bronch with photo tx today.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-10 00:00:00.000", "description": "Report", "row_id": 1602446, "text": "Nursing Progress Note 0700-1900\nAble to wean off Neosynephrine. pt remains on vasopressin, 0.04 units/min w/ MAPs 60-70. restarted insulin gtt. remains sedated on fentanyl and versed. slight increase in urine output this shift. afebrile. no further fluid boluses. recieved 2 units RBC's for hct of 26. Had photodynamic therapy todat, bronchoscopy delivered laser light directly onto obstructing R mainstem tumors.\n\nROS-\n\nCV- NSR w/ frequent multifocal PVC's several episodes of Bigeminy. HR 70-90's. ABP 90-120's systolic. extremities warm and very edematous. repeat hct pending. CVP 6-8, which has remained unchanged despite previous fluid boluses.\n\nRESP- no vent changes made. AC 14x600/10/40%. LS much more coarse today than previously, after multiple IVF boluses. small amounts thick white secretins. L lobe pna persists. CT site evaluated by pulmonology today after several days of heavy oozing from site and decrease in pleuravac output. ?kink of CT, readjusted, new dressing applied and CT placed on 10cm suction. No respiratory vairations in CT, team aware. less serous drainage noted from site after adjusted and placed to suction. o2 sats >95%\n\nNEURO- sedated on 25 mcg/hr fentanyl and 0.5 mg/hr versed. arousable to stimulus. follows commands inconsistantly. denies pain when asked.\n\nGI- TF's restarted. probalance currently at 30cc/hr, goal 65 cc/hr. abd soft, active BS's. rectal tube in place, draining liquid tan diarrhes. positive for CDiff. insulin gtt currently at 3units/hr w/ FS's 120's.\n\nGU- foley draining 15-50cc/hr dark yellow urine.\n\nSKIN- stage 2 pressure ulcer to coccyx. duoderm removed, DSD covered w/ tegaderm applied. skin otherwise intact. remains on photosensitivity precautions d/t phototherapy side effects.\n\nID- wbc;s up to 15 today (1.1 2 days ago). source of suspected sepsis remains unknown. BC's pending. started on flagyl for Cdiff. on multiple IV abx.\n\nSOCIAL- family in to visit. updated on progress/ plan.\n\nPLAN- ?attempt to turn off vasopressin, goal MAP's 60-65. q1hr fingersticks, adjust insulin gtt as needed. monitor CT site for drainage. also monitor resp status closely as pt recieved photodynamic therapy today and may develop plugs, airway inflammation, etc as a result.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-11 00:00:00.000", "description": "Report", "row_id": 1602447, "text": "Resp Care,\nPt. remains intubated on A/C overnoc. No vent changes this shift. Developed audible cuff leak this am. ET advanced to 24 cm, x-ray pending. Suctioned thick yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-12 00:00:00.000", "description": "Report", "row_id": 1602454, "text": "RESPIRATORY CARE NOTE\nREMAINS ON A/C NO VENT CHANGES. B.S. COARSE WITH DECREASED AREATION RLL. PT.NOT BRONCHED TODAY PLAN FOR BRONCH IN OR ON MONDAY.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-12 00:00:00.000", "description": "Report", "row_id": 1602455, "text": "MICU NPN Addendum:\n Residual check at 1900--300 cc. 180 cc refed to patient, remainder discarded. TF off, residual to be rechecked in 1 hour.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-13 00:00:00.000", "description": "Report", "row_id": 1602456, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Pt. tachypneic with RR mid 30's. Sx'd/lavaged for sm amount of thick tan secretions. Bs few insp crackles R base otherwise lungs clear. R CT to sx. No air leaks. Sedation increased via RN. Tachypnea resolving. Worsening metabolic acidosis. Vent settings unchanged. Vt 600, A/c 14 with total RR 18-22, Fio2 50% and Peep 10. S/P PDT. Plan: Continue with mechanical support. Bronchoscopy planned for Monday in OR. Wean Fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-13 00:00:00.000", "description": "Report", "row_id": 1602457, "text": "7p to 7a Micu Progress Note\n\nEvents overnight - pt agitated with RR low 30's and MV's up to 20 at onset of shift. HR slightly elevated at 105 ST. Bolused with 50 mcgs fentanyl without improvement. Pt bag lavaged for thick brownish plug with eventual improvement in resp status. BP labile and u/o poor throughout the noc - treated with a total of 3 L ivf ( 1 L NS and 2 L LR) with improvement in BP but little effect on u/o.\n\nNeuro - Pt follows commands and nods head in response to questions. MAE. Sedated with .5 mg/hr versed and weaned down to 15mcgs/hr fentanyl.\n\nResp - Vent settings unchanged - AC 14/600/50%/10 peep. RR 18-32. 02 sats 94-100%. ABG 119/29/7.27/14. LS coarse, diminished R base. Sx q 3-4 hrs for thick tan sputum and for plug as reported above. ? need for repeat bronch today. Chest tube to 10cm sx draining ~ 20ccs straw colored fluid. Pt saturating CT dssg x 1 with fluid. + fluctution, no air leak or crepitus detected.\n\nC-V - HR 85-105 ST with freq PVCs and occasional vent bigeminy. BP 78-130/50-60 with MAP < 60. As per above, 3 fluid boluses given to support BP with goal of maintaining MAP ~70. CVP 9-11.\n\nF/E - TFB + ~ 3 liters yest. Urine output scant,averaging 5-10ccs/hr. Given fluid boluses with max u/o 30ccs/hr. BUN 71 Creat 2.3 ( slightly elevated). K 4.1. Serum C02 12. ABG 119/29/7.27/14 -pt with worsening metabolic acidosis - MD notified, no bicarb administered.\n\nGI - Abd soft with absent BS. TF held as residuals high on previous shift and ? pt to have bronch today. Reglan initiated q 6 hrs iv. No stool - pt given senna and one dulcolax pr without results.\n\nID - Pt remains hypothermic with oral temp 96.8, rectal temp 97.4. WBC 18.7. Rx with ceftaz for GNR's in sputum and flagyl for c-diff.\n\nSkin - 2+ edema upper and lower exts. Weeping severely from upper exts and edematous scrotum. Arms elevated on pillows and scrotum supported with sling.\n\nEndo - BS very labile running from 135-206 ( see careview) despite pt being NPO. Insulin drip currently infusing at 4 units/hr.\n\nSocial - Dtr and wife called on phone. Updated on pts condition by RN.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-13 00:00:00.000", "description": "Report", "row_id": 1602458, "text": "Nursing Progress Note 0700-1900\nPt hypotensive this am ABP 70's/30's. recieved 1000cc LR bolus w/ no change in BP. placed back on neosynephrine, titrated up to current dose of 2.0mcg/kg/min w/ MAP's apporx 65. vasopressin also added this afternoon, at 0.04 units/min. hypothermic early in shift, w/ temp consistently 96.0. ?septic response. pan cultured. rewarmed w/ blankets up to 97.9. Vanco and Cipro added to abx regimen. Bronched at bedside to assess effects of photodynamic therapy.\n\nROS-\n\n pt into Afib at start of shift. HR 70-100's. frequent multifocal PVC's and bigeminy. CVP 8-12. anasarca w/ + pitting edema throughout SC tissues. severe scrotal edema. oozing from hands/ arms/ scrotum. extremities cool. INR 1.8, given SC Vit K. LFT's checked, WNL.\n\nRESP- Peep decreased to 7, otherwise vent settings unchanged. AC 14X600/50%/7. LS coarse w/ crackles in L base, diminished but improved R lower lobe breath sounds. o2 sats >95%. bronchoscopy today showed large amount of necrotic tissues, to be removed tomarrow. no interventions done. suctioning thick tissue-type secretions from ETT. bronch also showed ETT in too far, repositioned out 2cm to 22 at lip. CT to 10cm suction. no respiratory variation. + crepitus around insertion site. pt continues to saturate CT dressings, team aware.\n\nNEURO- sedation unchanged, fentanyl 15mcg/hr and versed 0.5mg/hr. easily arousable. makes eye contact shakes yes/no but not following commands. UE movement noted, but not in LE's. denies pain.\n\nGI-GU- TF's restarted at 20cc/hr. probalance goal of 65cc/hr. insulin gtt off most of am d/t low BS's of 60's and 70's. restarted at 1700. hypoactive bowels sounds. remains on reglan. small stool X 1 this shift. C Diff +.\n\nSKIN- stage 2 decub to coccyx, covered w/ duoderm. previously placed duoderm to R scapula remains in place. skin very thin and tears easily, especially around CT site.\n\nID- Ceftz, Flagyl, Cipro and Vanco for abx coverage. hypothermic, ?septic response.\n\nPLAN- to OR for rigid bronch and R mainstem debridement tomarrow. NPO after MN. adjust vasopressors as need to maintain MAP <65 and according to u/o. no further NS fluid boluses at this time. If pt needs fluids, D5W w/NaHCO3 to be given. ?acidosis d/t hyperchloridemia (from multiple liters of NaCl). ?use hespan if intravascularly dry. pan cultures pending. Please note: pt may need additional Vit K and/or FFP in am if coags remain elevated- planning to go to OR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-13 00:00:00.000", "description": "Report", "row_id": 1602459, "text": "RESPIRATORY CARE NOTE\nA/C 600 X 14 50 PEEP DECREASED TO 7. PT. BRONCHED AT BEDSIDE TUBE OUT 2 CM, 22 AT LIP. ABG 729/29/102/15/-10/100. PLAN TO TAKE TO OR TOMMORROW, FOR BRONCH.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-14 00:00:00.000", "description": "Report", "row_id": 1602460, "text": "Respiratory Care:\n\nPatient remains intubated/sedated on mechanical support. Current vent settings Vt 600, A/c 14, Fio2 40%, and Peep 7. Bs slightly coarse with faint crackles L base. Sx'd for sm amount of thick white secretions. Atrovent MDI given Q4hr. Peep/Fio2 weaned yesterday. Pt. maintaining good O2 sats 97-100%. Metabolic acidosis, ARF. S/P PDT. Plan rigid bronch in OR later today. R CT to sx. No further changes made. Plan: Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-14 00:00:00.000", "description": "Report", "row_id": 1602461, "text": "7p to 7a Micu Progress Note\n\nNeuro - Pt remains sedated with 15mcgs/hr of fentanyl and .5mg/hr versed. Intermittently following commands. Appears very fatigued. Hands restrained as pt occasionally pulling at ETT.\n\nResp - Remains orally intubated and vented on AC 14 x 600 40% and 7 peep. RR 18-26. 02 sats 97-100%. LS coarse with occas crackles L base. Sx for sm amts thick tan sptum q 4hrs. ABG this am 7.34/24/69/- - will increase fio2 to 50% and repeat ABG. If ABG not improved ? need to increase peep. CT to 10 cm sx draining ~50ccs serous fluid plus leakage around dssg.\n\nC-V - HR 85-90 Afib with occas periods of NSR accompanied by freq pvcs. Pt receiving 200 amiodarone po qd. Continues on neo and vasopressin to maintain MAP > 65. Neo currently infusing at 1.0 mcgs/kg/min and vasopressin at .04 units/min. BP 100-135/50-60.\nCVP 6-10 ( positional).\n\nGI - Abd soft. Hypoactive BS. TF held after MN for planned rigid bronchoscopy in OR today. Pt is add-on. Last stool yesterday pm.\n\nHeme - Hct stable at 33.9. PT 17.5. PTT 150 INR 2.0. MD notified - will give 10 mg vit K sq and sent T+S to BB for ? transfusion of FFP prior to OR.\n\nF/E - TFB + ~ 5 liters yest. Urine output increasing to 10-50ccs/hr via foley catheter. Pt continues to experience metabolic acidosis as per above ABG. No NS infusions ( IVF D5w) as acidosis from elevated chloride level attributed to multiple NS IVF infusions. BUN 72 Creat 2.4. K 4.0.\n\nID - Axillary temps 97.6 , rectal temp 99.8. WBC elevated to 23.8 from 18.7. Current antibiotic regime consists of ceftax, flagyl, cipro and vanco.\n\nSkin - Duoderms intact on coccyx and posterior thorax. Pt continues to weep copious amts of fluid from arms, draining serosanguinous fluid from L hand.\n\nEndo - Insulin drip titrated to maintain BS 90 - 130 ( see careview). Currently drip being held.\n\nSocial - Wife and dtr visited last eve and called on phone for updates.\n\nPlan - Pt to go to OR today for rigid bronch to remove necrotic tissue. Pending results - plan is for swan placement to further assess fluid status vs discussion with family to address whether instituting comfort measures only would be a more appropriate course to take.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-14 00:00:00.000", "description": "Report", "row_id": 1602462, "text": "Resp. Care Note\nPt received intubated and vented on AC settings with no change in vent parameters this shift. Pt did not go to OR for rigid bronch due to hemodynamics. Pt received a flexible bronch at bedside by interventional pulmonary dept. for clean out of necrotic tissue. BS coarse bilat at times, sxn for small amounts of tannish secretions. cont to receive atrovent MDI Q vent check. Cont current support.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-14 00:00:00.000", "description": "Report", "row_id": 1602463, "text": "ALTERED RESP STATUS\nD: PT EFFECTIVELY SEDATED ON VERSED GTT AT 0.5 MG/HR AND FENTANYL GTT AT 15 MCG/HR. PT LESS AWAKE TODAY TODAY AND DOES OPEN EYES WITH FREQ VERBAL STIMULATION. PT INCONSISTENT IN FOLLOWING COMMANDS AND DOES NOT CONSISTENTLY NOD YES OR NO TO QUESTIONS ASKED. PT MOVING UPPER EXTREMITIES BUT HAVE NOT OOBSERVED MOVEMENT OF LOWER EXTREMITIES BUT THIS BE LIMITED BECAUSE OF PT'S TOTAL BODY ANASARCA.\n\nRESP: PT REMAINS EXTREMELY PHOTOSENSITIVE B/CAUSE OF HIS PDT TX. INTUBATED ORALLY WITH VENT SETTINGS AT 50%/600/AC 14 WITH 7 PEEP AND O2 SATS> 98%. LUNGS COARSE BIL ON AUSCULTATION AND DIMINISHED TO R BASE. R CT TO 20 CM SUCTION WITH NO AIR LEAK AND A TOATL OF 205 CC'S SEROUS DRAINAGE. PT UNABLE TO GO TO OR FOR RIGID BRONCH B/CAUSE OF THE NEED FOR 2 PRESSORS FOR BP SUPPORT SO BRONCHOSCOPY DONE AT THE BEDSIDE WHICH PT WELL. BASED ON THE FINDINGS DR. SPOKE WITH PT'S DAUGHTER AND INFORMED HER THAT CLINICALLY THE R LUNG WAS UNCHANGED AND THAT THEY HAD NO OTHER TX'S TO OFFER PT. PT'S DAUGHTER ALSO SPOKE INDIVIDUALLY WITH DR. FROM HEME/ONC WHO ALSO EXPLAINED TO THE FAMILY THAT HIS PROGNOSIS WAS EXTREMELY POOR BUT PT'S DAUGHTER FEELS THAT SHE NEEDS TO GIVE HER FATHER MORE TIME TO RECOVER. SUCTIONED ETT FOR THICK YELLOW SPTUM. WILL CONT WITH RESP TOILETING AND OBSERVE RESP STATUS.CORTISOL LEVELS DRAWN AND PT WAS GIVEN 250 MCG IVP CORTISOL AND ALSO WAS STARTEDO N DEXAMETHASONE 4 MG IVP Q 8 HRS.\n\n\nCV: HR HIGH 80-100'S WITH SBP AS LOW AS 81 SYSTOLICALLY REQUIRING NEO GTT TO BE INCREASED TO 3 MCG/KG/MIN AND VASOPRESSIN REMAINS 0.04U/MIN. GOAL IS TO KEEP MAP> 65 WILL ALSO FOLLOW CVP AND IF 4-8 RANGE AND HYPOTENSIVE WILL NOTIFY MD AND NEED TO GIVE ADDITIONAL IVF BOLUSES. FOLLOW ELECTROLYTES CLOSELY AND REPLETE AS NEEDED. ? IF HYPOTENSION IS SECONDARY TO PT BEING SEPTIC.\n\n\nGI: OGT IN PLACE AND HAD BEEN NPO BUT TUBE FDGS OF PROBALANCE HAVE BEEN RESTARTED AT 30 CC'S/HR. PT INCONTINENT OF LG SOFT BROWN STOOL THAT IS GUIAC NEG. HCT STABLE AT 31. ABD SOFT AND NONTENDER WITH HYPOACTIVE BS ON ASUCULTATION. WILL CHECK RESIDUALS CLOSELY. PT STILL RECEIVING REGLAN 10 MG IV Q 6 HRS. ALBUMIN 1.5.\n\nGU: PT CONTINUES WITH BORDERLINE HOURLY UO AND BUN=72 AND CREAT=2.4. I&O FOR LOS POS 33 L AND PT HAS TOTAL BODY ANASARCA. URINE FOR ELECTROLYTES SENT OFF.\n\nID:MAX TEMP=98.6 ORALLY AND WBC ELEVATED AT 23.8. INR UP TO 2 AND PTT OF 150. WILL FOLLOW COAGS AS ORDERED. CONTINUES TO RECEIVE VANCOMYCIN,CLINDAMYCIN AND CEFTAZIDINE. FOLLOW FEVER CURVE AND IF PT SPIKES FEVER WILL PT .\n\n\nSOCIAL: PT'S DAUGHTER AND WIFE HAVE MET WITH MULTIPLE MD'S THROUGHOUT THE DAY AND HAVE BEEN INFORMNED THAT HIS PROGNOSIS IS EXTREMELY GRAVE. PLAN IS FOR TO MEET WITH DR. TOMORROW AM AT 1030. WILL CONTINUE WITH PRESENT MEDICAL REGIME AND KEEP FAMILY WELL INFORMED AND OFFER THEM EMOTIONAL SUPPORT. PT AT THIS TIME IS A FULL CODE.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-16 00:00:00.000", "description": "Report", "row_id": 1602468, "text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) with no changes made to any settings. Morning abg results revealed a partially compensated metabolic acidemia, even with 3 amps of HCO3 given.\n\nRSBI = 30 on 5cm PSV and 0-PEEP. No SBT done due to the level of anxiety the RSBI appeared to create.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-16 00:00:00.000", "description": "Report", "row_id": 1602469, "text": "Nursing Progress Note 0700-1900\nPt remains on vasopressors. continued at previous rates of 0.04 vasopressin and 2.0 neosynephrine for most of shift. sedation shut off at 1300 so family could see pt and talk with him. at time of this writing, pt still off sedation while family is visiting. tried to wean off neo while pt awake and agitated, but unable to. currently at 1.0mcg/kg/min neo. resting unconfortably. grimaces w/ any movement. vent changed to PS 15/7 w/ abg 7.22/30/70. peep increased to 10. unable to recheck abg, Aline found pulled out. team , need to be replaced.\n\nROS-\n\nCV- Afib, HR 80-100's, frequent multifocal PVC's. extremities cool and very edematous. L fingers cyanotic, please monitor.\n\nRESP- PS 15/10/50% w/ TV's 600-700 and MV's 13-18. spo2 95-98% on current vent settings. LS very coarse. suctioning necrotic, bloody tissue from ETT. CT site dressing changed twice. remains at 10cm suction. approx 100cc out this shift.\n\nNEURO- was on fentanyl 50mcg/hr and versed 1mg/hr, comfortably sedated. when awake, grimacing and trying to pull at ETT. bilat soft wrist restraints applied. MAE. follows commands inconsistently.\n\nSKIN- total body anasarca. oozing large amounts of serous fluid from every break in skin integrity, especially UE's, scrotum, and R scapular region. pads changed mamny times throughout shift. stage 2 decub to coccyx. newly formed black eschar to wound. duoderm falling off, reapplied. hair noted to be falling out.\n\nGI/GU- TF's, probalance, advanced to 50cc/hr. residuals consistantly 30-40cc. abd distended, hypoactive. no stool. insulin gtt reduced to 2 units/hr this am, BS's 110-130 on 2 units. Very poor u/o, approx 5-10cc/hr. positive approx 37 liters LOS (does not account for fluid losses through skin!)\n\nID- repeat BC's sent. remains on multiple IV abx and ambisome for fungemia. afebrile.\n\nSOCIAL- daughter and wife in to see pt. discussed possible patient outcomes, including probable grave prognosis w/ daughter. also discussed patient's discomforts. daughter and wife tearful but continue to insist on more time for abx's to try to clear infection. SW involved. given support.\n\n pt is CPR not indicated, but continue to vasopressors at this time. provide for patients comfort, adjusting fentanyl and versed accordingly. replace Aline, check abg.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-16 00:00:00.000", "description": "Report", "row_id": 1602470, "text": "RESPIRATORY CARE NOTE\nPT WEANED TO PSV. 15/7 50%, ABGS 734/30/70/17/-. PEEP INCREASED TO 10. NO ABGS, PT. HAVING INCREASED MV WITH DECREASED SEDATION.\n" }, { "category": "ECG", "chartdate": "2200-04-19 00:00:00.000", "description": "Report", "row_id": 189308, "text": "Probable idioventricular rhythm and ventricular paced rhythm new from previous\n\n" }, { "category": "ECG", "chartdate": "2200-04-13 00:00:00.000", "description": "Report", "row_id": 189309, "text": "Atrial fibrillation\nFrequent multifocal ventricular premature complexes\nIndeterminate frontal QRS axis\nGeneralized low QRS voltages\nRight bundle branch block\nConsider chronic pulmonary disease\nClinical correlation is suggested\nSince previous tracing of -4, no significant change\n\n" }, { "category": "ECG", "chartdate": "2200-04-14 00:00:00.000", "description": "Report", "row_id": 189310, "text": "Atrial fibrillation/flutter\nIndeterminate frontal QRS axis\nRight bundle branch block\nBorderline low voltage\nClinical correlation is suggested\nSince previous tracing of , ventricular ectopy not seen and ventricular\nrate increased\n\n" }, { "category": "ECG", "chartdate": "2200-04-09 00:00:00.000", "description": "Report", "row_id": 189311, "text": "Atrial fibrillation with ventricular paced beat and ventricular premature\nbeats. Low limb lead voltage - is non-specific. Right bundle-branch block.\nSince the previous tracing of ventricular ectopy and a ventricular\npaced beat are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2200-04-09 00:00:00.000", "description": "Report", "row_id": 189312, "text": "Atrial fibrillation. Low limb lead voltage - is non-specific. Right\nbundle-branch block. Since the previous tracing of sinus rhythm is now\nabsent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2200-04-07 00:00:00.000", "description": "Report", "row_id": 189313, "text": "Sinus rhythm\nBorderline first degree A-V block\nLeft atrial abnormality\nRight bundle branch block\nNo previous tracing\n\n" } ]

[ { "category": "Physician ", "chartdate": "2202-09-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390125, "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 Currently saturating in mid-90s on nasal cannula\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:00 PM\n Metoprolol - 06:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Emesis, No(t) Diarrhea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: Delirious\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:06 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: 76 (71 - 81) bpm\n BP: 125/57(75) {94/49(68) - 139/94(103)} mmHg\n RR: 16 (14 - 20) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50 kg (admission): 44.7 kg\n Total In:\n 340 mL\n 88 mL\n PO:\n TF:\n IVF:\n 340 mL\n 88 mL\n Blood products:\n Total out:\n 265 mL\n 115 mL\n Urine:\n 265 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -27 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, dysarthric but\n trying to speak and interact more\n Labs / Radiology\n 9.7 g/dL\n 364 K/uL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 35 mg/dL\n 104 mEq/L\n 143 mEq/L\n 32.3 %\n 15.8 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n WBC\n 9.6\n 12.2\n 14.3\n 15.8\n Hct\n 28.3\n 30.6\n 30.1\n 32.3\n Plt\n 247\n 259\n 333\n 364\n Cr\n 0.8\n 0.7\n 0.8\n 0.9\n TropT\n 0.50\n 0.50\n 0.55\n 0.75\n 0.72\n Glucose\n 119\n 103\n 134\n 119\n Other labs: PT / PTT / INR:18.3/33.9/1.7, CK / CKMB /\n Troponin-T:87/8/0.72, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Encephalopathy slightly improved today - more\n interactive and trying to communicate but dysarthric and still seems\n confused\n 2) Increased Cough/O2 Requirement: Treating for CAP with azithro and\n CTX ( of CTX). Getting steroid course for COPD - cutting\n methylprednisolone 60mg daily. Better today\n 3) CHF:Has aortic stenosis as well as hypokinetic LV. High BNP with\n episode of respiratory distress. Seems compensated at the moment\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Echo", "chartdate": "2202-09-02 00:00:00.000", "description": "Report", "row_id": 63650, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA. Left ventricular function\nHeight: (in) 64\nWeight (lb): 101\nBSA (m2): 1.46 m2\nBP (mm Hg): 97/28\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 11:12\nTest: Portable TTE (Congenital, 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. Normal LV cavity size. Low normal\nLVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Focal calcifications in aortic\narch.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Severe AS (area 0.8-1.0cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Severe mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.] Prolonged (>250ms)\ntransmitral E-wave decel time. LV inflow pattern c/w impaired relaxation.\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 size is normal. Overall left ventricular\nsystolic function is low normal (LVEF 50%). There is no ventricular septal\ndefect. The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated with severe global free wall hypokinesis. There\nare focal calcifications in the aortic arch. There are three aortic valve\nleaflets. The aortic valve leaflets are moderately thickened. There is severe\naortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. There\nis severe mitral annular calcification. Mild (1+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The left ventricular inflow pattern suggests\nimpaired relaxation. The tricuspid valve leaflets are mildly thickened. There\nis moderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (images reviewed) of , the aortic regurgitation is significantly increased, and the right\nventricle is now severely hypokinetic. Left ventricular function also appears\nworse.\n\n\n" }, { "category": "ECG", "chartdate": "2202-09-01 00:00:00.000", "description": "Report", "row_id": 124470, "text": "Probable reversed left and right arm leads. Sinus rhythm with atrial\npremature beats. Consider biatrial abnormality. Indeterminate axis.\nLow limb lead QRS voltage. Delayed R wave progression. QTc interval\nappears prolonged but it is difficult to measure. Diffuse T wave changes\nare suggested but baseline artifact makes assessment difficult. Findings\nare non-specific. Clinical correlation is suggested. Since the previous\ntracing of atrial flutter is absent, left and right arm leads are\nprobably reversed, limb lead QRS voltage is lower and further ST-T wave changes\nmay be present but baseline artifact makes comparison difficult.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2202-09-01 00:00:00.000", "description": "Report", "row_id": 124427, "text": "Sinus rhythm with atrial premature beats. Consider biatrial abnormality.\nIndeterminate axis. Low limb lead QRS voltage. Delayed R wave progression.\nThe QTc interval may be prolonged but it is difficult to measure. Diffuse\nST-T wave changes. Findings are non-specific. Clinical correlation is\nsuggested. Since the previous tracing of the same date left and right arm leads\nare now in normal position. Otherwise, baseline artifact on both tracings\nmakes comparison difficult.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2202-09-11 00:00:00.000", "description": "Report", "row_id": 124423, "text": "Sinus rhythm with premature ventricular contractions. Extensive ST-T wave\nchanges may be indicative of myocardial hypertrophy versus myocardial ischemia.\nThere is also left atrial abnormality. Compared to the previous tracing\nof there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2202-09-08 00:00:00.000", "description": "Report", "row_id": 124424, "text": "Sinus rhythm. Frequent ventricular premature beats. Diffuse ST-T wave\nabnormalities. Cannot rule out myocardial ischemia. Compared to the previous\ntracing of frequent ventricular premature beats are new. Arm lead\nreversal has been corrected. Diffuse ST-T wave abnormalties persist. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2202-09-05 00:00:00.000", "description": "Report", "row_id": 124425, "text": "Baseline artifact. Arm leads are reversed. Sinus rhythm with atrial premature\nbeats. RSR' pattern in leads V1-V2 with Q-T interval prolongation and T wave\ninversions in the precordial leads. Since the previous tracing the\nQ-T interval is longer and T wave inversion is new. Suggest repeat tracing and\nclinical correlation.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2202-09-03 00:00:00.000", "description": "Report", "row_id": 124426, "text": "Sinus tachycardia. Borderline low limb lead voltage. Baseline artifact.\nQ waves in leads V1-V2. Consider septal myocardial infarction. Since the\nprevious tracing the rate is faster. Atrial premature beats are no\nlonger present.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 389890, "text": "81 yo F with prior CVA, copd, severe AS and h/o adeno carcinoma adm\n with 2 d h/o altered MS and finally obtundation and an increased O2\n requirement, Brought to ED where altered MS. by neuro to r/o\n stroke. CXR read as possible PNA, cardiac enzymes done with Troponin\n .05\n Alteration in Nutrition\n Assessment:\n Pt lethargic, barely arousable,\n Action:\n Pt started on IVF d51/2 with 20 kcl at 75cc/hr, Pt sat up right,\n attempted to arouse and attempted to have pt taken small bite of\n applesauce\n Response:\n Pt did not attempt to take any po intake, po meds held, pt is not awake\n enough to perform speech and swallow but should have consult when more\n alert\n Plan:\n Cont to monitor pt neuro status, schedule speech and swallow when more\n alert, continue with mild fluid rehydration due to cardiac hx\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Ls clear with O2 sats 98% on 4l nc, pt is former smoker., temp\n max 100.4 rectal\n Action:\n Pt turned frequently, antibiotics changed to azithro and ceftriaxone,\n Response:\n Ls remain clear, rr teens, o2 sats 98& on 4l nc,\n Plan:\n Cont with frequent turning etc, wean O2 as tolerated , cont with antb.\n Cxr in am\n Altered mental status (not Delirium)\n Assessment:\n Pt sleeping most of the day, arousable to voice, pt will say her name\n and will respond with\nhome\n if asked where she is , pt answering\n questions with one word sporadically, voice is clear to garbled, perrla\n at 2mm\n Action:\n Eeg done to r/o seizure activity, and repeat MRI done early am,\n Response:\n Eeg negative for seizures, MRI showing atherosclerotic areas as well\n as multi small areas of restricted diffusion r/t embolic source\n Plan:\n Cont with q 4 hr neuro checks , pt to be called out to neuro floor,\n futher work up to determine ? source of infection as reason for ms\n changes\n .H/O cardiac dysrhythmia other\n Assessment:\n Hr 70 sr with pacs and frequent pvc\ns, am k+ 3.5,\n Action:\n Cardiac echo done, K+ repleted with 20 in IVF d51/2 ns\n Response:\n VSS, ? need for follow-up EKG , no further cardiac enzymes ordered.\n Plan:\n Cont to monitor VS, check lytes and replete as needed, if pt remains\n NPO ? starting IV betablocker.\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 389891, "text": "81 yo F with prior CVA, copd, severe AS and h/o adeno carcinoma adm\n with 2 d h/o altered MS and finally obtundation and an increased O2\n requirement, Brought to ED where altered MS. by neuro to r/o\n stroke. CXR read as possible PNA, cardiac enzymes done with Troponin\n .05\n Alteration in Nutrition\n Assessment:\n Pt lethargic, barely arousable,\n Action:\n Pt started on IVF d51/2 with 20 kcl at 75cc/hr, Pt sat up right,\n attempted to arouse and attempted to have pt taken small bite of\n applesauce in the morning\n Response:\n Pt did not attempt to take any po intake, po meds held, pt is not awake\n enough to perform speech and swallow but should have consult when more\n alert\n Plan:\n Cont to monitor pt neuro status, schedule speech and swallow when more\n alert, continue with mild fluid rehydration due to cardiac hx\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Ls clear with O2 sats 98% on 4l nc, pt is former smoker., temp\n max 100.4 rectal\n Action:\n Pt turned frequently, antibiotics changed to azithro and ceftriaxone,\n Response:\n Ls remain clear, rr teens, o2 sats 98& on 4l nc,\n Plan:\n Cont with frequent turning etc, wean O2 as tolerated , cont with antb.\n Cxr in am\n Altered mental status (not Delirium)\n Assessment:\n Pt sleeping most of the day, arousable to voice, pt will say her name\n and will respond with\nhome\n if asked where she is , pt answering\n questions with one word sporadically, voice is clear to garbled, perrla\n at 2mm\n Action:\n Eeg done to r/o seizure activity, and repeat MRI done early am,\n Response:\n Eeg negative for seizures, MRI showing atherosclerotic areas as well\n as multi small areas of restricted diffusion r/t embolic source\n Plan:\n Cont with q 4 hr neuro checks, pt to be called out to neuro floor,\n further work up to determine? source of infection as reason for ms\n changes\n .H/O cardiac dysrhythmia other\n Assessment:\n Hr 70 sr with pacs and frequent pvc\ns, am k+ 3.5,\n Action:\n Cardiac echo done, K+ repleted with 20 in IVF d51/2 ns\n Response:\n VSS, ? need for follow-up EKG , no further cardiac enzymes ordered.\n Plan:\n Cont to monitor VS, check lytes and replete as needed, if pt remains\n NPO ? Starting IV beta-blocker.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n Height:\n Admission weight:\n 44.7 kg\n Daily weight:\n 45.8 kg\n Allergies/Reactions:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Precautions:\n PMH: COPD, Diabetes - Insulin, ETOH\n CV-PMH: Hypertension\n Additional history: Previous Right MCA stroke (no residual defecit),\n Osteoperosis, Depression.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:53\n Temperature:\n 100\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,287 mL\n 24h total out:\n 313 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:28 AM\n Potassium:\n 3.5 mEq/L\n 03:28 AM\n Chloride:\n 100 mEq/L\n 03:28 AM\n CO2:\n 35 mEq/L\n 03:28 AM\n BUN:\n 23 mg/dL\n 03:28 AM\n Creatinine:\n 0.7 mg/dL\n 03:28 AM\n Glucose:\n 103 mg/dL\n 03:28 AM\n Hematocrit:\n 30.6 %\n 03:28 AM\n Finger Stick Glucose:\n 246\n 10:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: bag of clothes with patient.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: SICU A\n Transferred to: 1110\n Date & time of Transfer: @\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 389892, "text": "81 yo F with prior CVA, copd, severe AS and h/o adeno carcinoma adm\n with 2 d h/o altered MS and finally obtundation and an increased O2\n requirement, Brought to ED where altered MS. by neuro to r/o\n stroke. CXR read as possible PNA, cardiac enzymes done with Troponin\n .05\n Alteration in Nutrition\n Assessment:\n Pt lethargic, barely arousable,\n Action:\n Pt started on IVF d51/2 with 20 kcl at 75cc/hr, Pt sat up right,\n attempted to arouse and attempted to have pt taken small bite of\n applesauce in the morning\n Response:\n Pt did not attempt to take any po intake, po meds held, pt is not awake\n enough to perform speech and swallow but should have consult when more\n alert\n Plan:\n Cont to monitor pt neuro status, schedule speech and swallow when more\n alert, continue with mild fluid rehydration due to cardiac hx\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Ls clear with O2 sats 98% on 4l nc, pt is former smoker., temp\n max 100.4 rectal\n Action:\n Pt turned frequently, antibiotics changed to azithro and ceftriaxone,\n Response:\n Ls remain clear, rr teens, o2 sats 98& on 4l nc,\n Plan:\n Cont with frequent turning etc, wean O2 as tolerated , cont with antb.\n Cxr in am\n Altered mental status (not Delirium)\n Assessment:\n Pt sleeping most of the day, arousable to voice, pt will say her name\n and will respond with\nhome\n if asked where she is , pt answering\n questions with one word sporadically, voice is clear to garbled, perrla\n at 2mm\n Action:\n Eeg done to r/o seizure activity, and repeat MRI done early am,\n Response:\n Eeg negative for seizures, MRI showing atherosclerotic areas as well\n as multi small areas of restricted diffusion r/t embolic source\n Plan:\n Cont with q 4 hr neuro checks, pt to be called out to neuro floor,\n further work up to determine? source of infection as reason for ms\n changes\n .H/O cardiac dysrhythmia other\n Assessment:\n Hr 70 sr with pacs and frequent pvc\ns, am k+ 3.5,\n Action:\n Cardiac echo done, K+ repleted with 20 in IVF d51/2 ns\n Response:\n VSS, ? need for follow-up EKG , no further cardiac enzymes ordered.\n Plan:\n Cont to monitor VS, check lytes and replete as needed, if pt remains\n NPO ? Starting IV beta-blocker.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n Height:\n Admission weight:\n 44.7 kg\n Daily weight:\n 45.8 kg\n Allergies/Reactions:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Precautions:\n PMH: COPD, Diabetes - Insulin, ETOH\n CV-PMH: Hypertension\n Additional history: Previous Right MCA stroke (no residual defecit),\n Osteoperosis, Depression.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:53\n Temperature:\n 100\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,287 mL\n 24h total out:\n 313 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:28 AM\n Potassium:\n 3.5 mEq/L\n 03:28 AM\n Chloride:\n 100 mEq/L\n 03:28 AM\n CO2:\n 35 mEq/L\n 03:28 AM\n BUN:\n 23 mg/dL\n 03:28 AM\n Creatinine:\n 0.7 mg/dL\n 03:28 AM\n Glucose:\n 103 mg/dL\n 03:28 AM\n Hematocrit:\n 30.6 %\n 03:28 AM\n Finger Stick Glucose:\n 246\n 10:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: bag of clothes with patient.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: SICU A\n Transferred to: 1110\n Date & time of Transfer: @ 2100\n" }, { "category": "Rehab Services", "chartdate": "2202-09-08 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 390392, "text": "Subjective:\n \"let me lay down\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - Lungs are hyperinflated consistent\n with COPD. No pulmonary edema or pneumonia.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n T\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 70\n 111/56\n 16\n 98%\n Activity\n 85\n 133/72\n 24\n 87% on\n Recovery\n 80\n /\n 18\n 95%\n Total distance walked: 0\n Minutes:\n Gait: unable to initiate steps in standing. total assist slide\n transfer from stretcher chair to bed.\n Balance: static sitting at edge of bed with mod-max A, mod-to-severe\n retropulsion in sitting, improved with removing RUE support. Max A\n static standing, retropulsive.\n Education / Communication: Reviewed PT and encouraged\n participation. Communicated with nsg re: status.\n Other: Pushing posteriorly with RUE\n +RUE balance reactions\n not following any commands\n opens eyes and localizes to voice\n Assessment: 81 yo F s/p CVA making slow steady progress in PT with\n mobility and arousal, continues to be limited by impaired cognition and\n significantly below her baseline level. Continue to recommend d/c to\n rehab when medically appropriate, PT to continue to follow and progress\n as able at acute level.\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 389765, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2202-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 389980, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to SICU on 3L NC. SATs 84-88%.\n Moaning and agitated. Not obeying commands, MAE.\n Afebrile.\n Lung sounds diminished.\n U/O < 30 cc/hr. Only 100cc since 0700 on 11.\n PVCs. HR 90\ns. BP WNL.\n Action:\n Shovel mask @ 40%, 12L.\n 2 mg iv morphine as ordered.\n Pt\ns daughter at bedside.\n DNR/DNI continued.\n Response:\n Positive effect with morphine administration. Resting, SATs 94-96%.\n Plan:\n Continue to monitor respiratory and cardiac status.\n Strict I&O.\n Keep MICU informed of any acute changes to pt\ns condition.\n" }, { "category": "Rehab Services", "chartdate": "2202-09-07 00:00:00.000", "description": "Attempted Swallowing Follow-Up", "row_id": 390291, "text": "TITLE: ATTEMPTED SWALLOWING FOLLOW-UP\nPatient transferred to ICU desaturations and trigger on the\nfloor on . We rerurned to follow-up with patient to determine\nif she may be appropriate for POs. RN reported patient continues\nwith altered mental status and not following commands.\nPatient was seated upright in the chair with eyes closed and\ncontinued moaning only. No response to verbal cues and patient\ndid not follow commands. Patient did accept ice chips and tsp on\nwater with max tactile cues. Swallow trigger was initiated with\nadequate laryngeal elevation. No overt difficulty noted. Patient\nthen clamped lips shut and refused to accept any further POs via\nspoon or cup.\nA/P: Ms. continues with altered mental status with\ncontinued moaning and not following commands. She accepted only\nlimited PO trials during today's attempted evaluation (ice chip\nand tsp of water) before clamping her lips shut and not accepting\nany further POs. Patient recommended to remain NPO at this time.\nRN reported patient's family refusing alternate means of\nnutrition at this time. Please reconsult once patient is\naccepting POs and we will be happy to return.\n_______________________________\n , MS, CCC-SLP\nPager #\nFace Time: 0900-0910\nTotal Time: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390372, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on NC with 1L O2, LS clear and diminished at base, O 2sat\n 90-98%\n Action:\n Chest PT , position changed q2h, dry mouth, Mouth care q4h with\n mouth moisturizer applied.\n Response:\n Regular breathing, weak cough productive. Suctioned form throat.\n Plan:\n Cont to monitor, pulm hygiene.\n Alteration in Nutrition\n Assessment:\n Patient is weak and lethargic, awake to call . Not on TF , Pt she\n is not hungry and \n to eat.\n Action:\n need speech and swallow eval before starting po\ns, mouth care done.\n Response:\n Unchanged.\n Plan:\n ? Speech and swallow eval if pt remains alert and awake during the day\n Altered mental status (not Delirium)\n Assessment:\n Patient is lethargic, opening eyes spont, garbled speech, oriented x1,\n able to say her last name, not aware of place or time.\n Action:\n Q4h neuro checks, reoriented to place and time.\n Response:\n Alert, oriented x1, MAE, PERL, following simple commands.\n Plan:\n Cont to monitor, neuro checks, reorient as needed\n" }, { "category": "General", "chartdate": "2202-09-02 00:00:00.000", "description": "Generic Note", "row_id": 389880, "text": "TITLE: Respiratory Care\n Started on bronchodilators; tolerating well. BS generally clear.\n" }, { "category": "Nursing", "chartdate": "2202-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390077, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n No c/o sob. No increased work of breathing or respiratory distress\n noted. Lungs cta bilat, diminished at bases.\n Action:\n Oxygen via nasal cannula. Frequent turning and repositioning.\n Response:\n Sats improved. Sat 90 to 96%. Pt remains on 3L via NC.\n Plan:\n Continue to wean from O2 as tolerates.\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be arouseable to voice. Moving all extremities on bed.\n Less movement noted lower extremities. Pupils equal and briskly\n reactive. Does not follow commands.\n Action:\n Q 2hr neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Continue close neuro assessment. Family support and teaching.\n" }, { "category": "Nursing", "chartdate": "2202-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390079, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n No c/o sob. No increased work of breathing or respiratory distress\n noted. Lungs cta bilat, diminished at bases.\n Action:\n Oxygen via nasal cannula. Frequent turning and repositioning.\n Response:\n Sats improved. Sat 90 to 96%. Pt remains on 3L via NC.\n Plan:\n Continue to wean from O2 as tolerates.\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be arouseable to voice. Moving all extremities on bed.\n Less movement noted lower extremities. Pupils equal and briskly\n reactive. Does not follow commands.\n Action:\n Q 2hr neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Continue close neuro assessment. Family support and teaching.\n" }, { "category": "Physician ", "chartdate": "2202-09-04 00:00:00.000", "description": "Physician Admission Note - MICU", "row_id": 390083, "text": "Chief Complaint: hypoxia\n HPI:\n This is an 81 year old female with h/o right sided MCA stroke with\n residual left hemiparesis, COPD, Atrial flutter, and partial\n gastrectomy for gastric cancer who initially presented with altered\n mental status and worsening left sided weakness. She was also noted to\n have worsening shortness of breath. She presented to the ED where she\n was found to be dyspneic, hypoxic, with a UTI, and suspected of having\n pneumonia. She also had a troponin of .57 and was therefore admitted\n to the MICU. She wa salso given levaquin. She was ruled out for a\n myocardial infarction in the MICU. Given her altered mental\n status and worsening left sided weakness, it was unclear whether\n she was just exhibiting recrudescence of her old stroke, vs. a\n new ischemic event. She underwent an MRI which showed multiple\n new small embolic strokes. As her multiple other medical\n problems were more stable at this point, the decision was made to start\n her on levenox for her embolic strokes and transfer her to the\n Neurology Stroke servic and transferred to the Neurology service on\n .\n The neurology team considered her new symptoms to be a recrudescence\n of her old stroke in the context of her UTI. Similarly, they felt her\n altered mental status could not be explained by the location or size of\n the new infarcts. She underwent an EEG which showed widespread\n encephalopathy, likely toxic metabolic. She also underwent a TTE which\n showed significantly worsening aortic regurgitation and a dilated and\n hypokinetic right ventricle, which are new findings compared with her\n most recent echo in .\n On the patient was found to be repeatedly hypoxic on the neurology\n floor. She wa on a face mask with 40% oxygen, but repeatedly removed\n the mask during which she desaturated to 85%. Her oxygen levels\n increased when her facemask was replaced. She was also found to be\n wheezy on exam. EKG showed psuedonormalization of T waves in V2 and\n V3. She was given albuterol nebulizers with improvement in her\n oxygenation. An ABG was performed which showed a lactate of 8.8. She\n was transferred to the MICU for treatment of hypoxia and elevated\n lactate.\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 01:04 PM\n Azithromycin - 02:04 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:30 PM\n Metoprolol - 06:32 PM\n Other medications:\n HISS\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Aspirin 81 mg PO DAILY\n Multivitamin daily\n Azithromycin 500 mg IV Q24H day 1 = \n Omeprazole 20 mg PO DAILY\n CeftriaXONE 1 gm IV Q24H Day 1= \n Fluoxetine 20 mg PO DAILY\n Lovenox 40 mg sc BID\n OUTPATIENT MEDICATIONS: (per records)\n ALBUTEROL 2 puffs po three times a day PRN\n BUPROPION HCL 100 mg PO daily\n FLUOXETINE 40 mg PO daily\n HYDROCHLOROTHIAZIDE 25 mg PO daily\n IPRATROPIUM BROMIDE MDI 4 */daily\n LISINOPRIL 5 mg daily\n OMEPRAZOLE 20 mg PO daily\n OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 4*/day PRN\n ACETAMINOPHEN 325-650 mg TID PRN\n DOCUSATE SODIUM 100 mg PO BID\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n -atrial flutter\n -History of right sided MCA ischemic stroke (residual mild left\n hemiparesis)\n -Severe aortic stenosis: TTE showed severe AS and diastolic\n heart failure.\n -Gastric adenocarcinoma s/p partial gastrectomy in \n -Hypertension.\n -Hyperlipidemia.\n -COPD (on 2L supplementary O2 by nasal cannula PRN)\n -Borderline glucose intolerance\n -Osteoporosis.\n -Depression.\n -History of alcohol abuse\n -History of pyloric stenosis.\n .\n .\n Family History: Parents died in their 70s of unknown causes.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Social History: She smoked 1ppd for 50 years. Has a history of\n alcohol abuse but none in five years per previous notes. Lives with\n her daughter and ambulates with a cane since her stroke\n Review of systems:\n Flowsheet Data as of 06:41 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.8\nC (98.2\n HR: 94 (78 - 108) bpm\n BP: 104/62(72) {104/53(63) - 127/67(82)} mmHg\n RR: 19 (16 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.8 kg (admission): 44.7 kg\n Total In:\n 1,372 mL\n 277 mL\n PO:\n TF:\n IVF:\n 1,372 mL\n 27 mL\n Blood products:\n Total out:\n 338 mL\n 28 mL\n Urine:\n 338 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,034 mL\n 249 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 94%\n Physical Examination\n PHYSICAL EXAM: 98.2 104/62 93 95% 40% facemask\n GEN: severely cachectic, somnulent, rouses to touch/loud voice with\n moans\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. Neck Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Faint mumur at\n apex. JVP= 7 cm.\n LUNGS: CTAB w/ dry crackles at bases, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Unable to answer questions reliably. Will intermittently say\n Yes, No, Okay. Intermittently able to follow simple commands (like move\n your right leg). L HF . L biceps 2+ reflex. R biceps 3+. L hand\n flacid. L leg below knee flacid w/ foot drop and upgoing toes. R leg\n hypertonic, with downgoing toes. No clonus on either side\n .\n Studies:\n EEG : Abnormal portable EEG due primarily to the disorganization\n and slowing of the background. This indicates a widespread\n encephalopathy. Metabolic disturbances, infection, and medications are\n among the most common causes. There were no prominent focal\n abnormalities, but encephalopathies may obscure focal findings. There\n were frequent sharp waves, usually symmetric, indicating areas of\n cortical hypersynchrony. This does not necessarily indicate the\n presence of seizures at other times.\n .\n ECHO - Overall left ventricular systolic function is low normal\n (LVEF 50%). There is no ventricular septal defect. The right\n ventricular free wall is hypertrophied. The right ventricular cavity is\n dilated with severe global free wall hypokinesis. The aortic valve\n leaflets are moderately thickened. There is severe aortic valve\n stenosis. Moderate (2+) aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen (which may be underestimated). The left\n ventricular inflow pattern suggests impaired relaxation.\n .\n CXR : There is a small right pleural effusion with adjacent\n atelectasis is very similar. Allowing for rotation, the appearance of\n the lung parenchyma is unchanged, with degree of emphysema. The cardiac\n silhouette is borderline in size. There is no pulmonary edema or\n pneumothorax.\n .\n MRI Head/Brain/Neck :\n 1. Multiple small acute infarcts, diffusely scattered in the cerebral\n and cerebellar hemispheres, on both sides, in the ACA, MCA and the PCA\n territories, likely related to an embolic source. To correlate\n clinically.\n 2. Patent major intracranial arteries without focal flow-limiting\n stenosis, occlusion or aneurysm more than 3 mm within the resolution of\n MR angiogram with bilateral fetal PCA variant and hypoplastic A1\n segment of the right anterior cerebral artery.\n 3. Suboptimal quality of the contrast-enhanced MR angiogram of the\n neck, which makes assessment inaccurate.\n .\n ekg: sinus tachycardia at rate of 117, normal axis, normal intervals,\n pseudonormalization of t waves in V2 and V3.\n Labs / Radiology\n 259 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 23 mg/dL\n 35 mEq/L\n 100 mEq/L\n 3.5 mEq/L\n 139 mEq/L\n 30.6 %\n 12.2 K/uL\n [image002.jpg]\n \n 2:33 A10/7/ 07:20 PM\n \n 10:20 P10/8/ 03:28 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.6\n 12.2\n Hct\n 28.3\n 30.6\n Plt\n 247\n 259\n Cr\n 0.8\n 0.7\n TropT\n 0.50\n 0.50\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:15.8/36.2/1.4, CK / CKMB /\n Troponin-T:91//0.50, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assessment and Plan:\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission. Flat CKs suggest troponin elevation either from stroke or\n more remote cardiac event.\n - continue to provide supportive measures s/p stroke\n - treat pneumonia as below\n 2) Increased Cough/O2 Requirement: Probable pneumonia\n (community-aquired), vs COPD flare.\n -CTX/Azithromycin to complete 7 day course\n -Continue ipratroprium and albuterol\n -methylprednisolone\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS/Elevated\n Troponin/Aflutter/HTN: Since last ECHO pt has deterioriating cardiac\n status with increased Aortic insufficiency and RV hypokinesis. ekg may\n have worrisome signs with pseudonormalization of T waves. Flat CKs\n suggest troponin elevation may be from remote cardiac event. ECHO\n suggest completed infarct. Concerned that pt stroke was from a\n showering of cardiac emboli.\n - hold lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - anticoagulation per neurology given recent mult embolic strokes\n - cont aspirin 81 mg daily\n - lopressor 5mg 5mg IV q6h\n - trend enzymes\n .\n 4)elevated lactate: potentially be from increased work of\n breathing. Is normotensive making septic shock unlikely.\n -continue antibiotics\n -oxygen supplementation\n .\n 5)multiple cerebral infarcts: lovenox 40mg . sourc of emboli has\n not been found.\n 4) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 5) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - please check iron studies, B12, folate as pt may need all of these\n repleted. If B12 is low pls give IM injection.\n 6) Leukocytosis: neg Urine cx, benign abd exam, on CTX/azithro to\n complete Community Aquired PNA course. also be reactive in setting\n of multiple acute strokes.\n - trend and culture pt (sputum, CXR, UA, stool for c. diff) if spikes\n temp <95 for > 100.5\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n ------ Protected Section ------\n I agree with the note above, including the assessment and plan. Please\n see my note from for further details.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:21 ------\n" }, { "category": "Nursing", "chartdate": "2202-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390280, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes spont and to call, not following\n commands, lifting UE, moving LE to pain, PERL.\n Action:\n Neuro checks q4h, Reoriented to place and time & activities. Encouraged\n for deep breath and cough.\n Response:\n Responding to verbal commands by turning head, not following commands.\n Plan:\n Cont to monitor, support to patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was on NC 3L, LS clear o2 sat 96-99%\n Action:\n O2 reduced to 2L by NC, HOB >30*, position changed q2h. Mouth care\n q4h.Nebs per order.\n Response:\n O 2sat 94\n 98 %, weak cough, no sputum. LS clear.\n Plan:\n Pulm hygiene, position q2h,\n" }, { "category": "Physician ", "chartdate": "2202-09-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390285, "text": "Chief Complaint:\n 24 Hour Events:\n - AM BNP was \n - Cardiac enzymes relatively stable, not decreasing\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:00 AM\n Metoprolol - 06:08 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 07:35 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 (98.4\n HR: 68 (67 - 81) bpm\n BP: 125/58(74) {104/49(65) - 138/92(97)} mmHg\n RR: 12 (11 - 16) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.2 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 540 mL\n 123 mL\n PO:\n TF:\n IVF:\n 540 mL\n 123 mL\n Blood products:\n Total out:\n 517 mL\n 330 mL\n Urine:\n 517 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23 mL\n -208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///29/\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 9.9 g/dL\n 123 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 47 mg/dL\n 108 mEq/L\n 146 mEq/L\n 32.4 %\n 16.6 K/uL\n [image002.jpg]\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n Plt\n 333\n 364\n 373\n 320\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n TropT\n 0.75\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n Other labs: PT / PTT / INR:16.1/40.5/1.4, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 81 year old female with severe aortic stenosis, aflutter who is now s/p\n multiple bilateral embolic infarcts in MCA, ACA, PCA territories with\n mental status change and periodic hypoxia and tachypnea.\n .\n 1) Hypoxia - Patient desaturated two days ago into the mid 80s and\n responded to morphine, high flow mask, and respositioning. Likely\n flash pulmonary edema, especially given severe AS. Has tenuous\n hemodynamics and periodic desaturations may be her baseline. Over last\n 24 hours has been weaned from high flow mask, now on nasal cannulus.\n Continuing tx of underlying PNA and possible COPD flare may help reduce\n degree of hypoxia.\n -Continue tx of underlying PNA with ceftriaxone and azithro (today is\n day final day of 7 day course)\n -Continue prednisone taper, currently getting 60 mg: tomorrow taper\n down to 20 mg\n -nebs PRN\n -Not a surgical candidate for AS; likely will continue to have periodic\n desaturations, key will be to keep blood pressure controlled and keep\n off fluid, however can't be aggressive w/ diuresis given that she's\n preload dependant. Getting lopressor 5 mg IV q6 hrs. BPs have been\n 125 - 140.\n .\n 2) Troponin elevation - Initially elevated secondary to CVA and have\n been stable at .75. Following recent desat, enzymes further increased\n but have been stable at .85 with no significant change in CK-MB\n fraction. Likely experienced some demand ischemia secondary to\n increased work of breathing.\n -Cardiology is aware\n -No change in management given she is already on lovenox for CVA\n .\n 3) Altered Mental Status: Change from baseline; unclear etiology.\n Likely encephalopathy in setting of recent stroke, may also have a\n contribution from infection as well as steroid course. Unclear if\n improving.\n - continue to provide supportive measures s/p stroke (maintaining BPs)\n - treat pneumonia as above\n - continue steroid taper\n .\n 4) Recent CVA - Secondary to ischemic stroke, bilateral, affecting PCA,\n MCA, ACA. Most likely embolic from cardiac origin given widespread,\n bilateral distribution and hx of aflutter.\n -Echo did not show any clot\n -Holding on carotid duplex as would not change management; not a\n surgical candidate\n -Continue lovenox 40 mg \n -continue aspirin 81 mg daily\n -Touch base with Neuro re: outpatient MRI; long-term anticoagulation.\n .\n 5 Leukocytosis: Stable at 16, likely secondary to prednisone course.\n -Follow after steroids are tapered\n .\n 6) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke and prednisone course.\n -HISS w/ treatment for FSG >200.\n .\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n .\n 10) Dispo - to floor pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 389755, "text": "Chief Complaint: Unresponsiveness/right sided weakness\n HPI:\n This is an 81 year old female with past medical history notable for\n right sided MCA stroke with residual left hemiparesis, COPD, Atrial\n flutter, and partial gastrectomy for gastric cancer who presented to\n the ED today with altered mental status as well as weakness this\n morning. The patient's daughter reports she had been in her normal\n state of health two days ago but yesterday seemed more confused and was\n coughing with an increased O2 requirement. At that time the patient's\n daughter spoke to the patient's PCP . , who recommended\n presentation to the ED for evaluation, the patient refused this however\n and thus stayed at home. This morning the patient was found in bed\n unresponsive and not speaking to her daughter. extremely altered and\n not responding in her normal way to her daughter. In fact she was\n barely responding at all and was unable to stand.\n The patient was brought to the the ED where she was obtunded with\n nonmoving left arm and hypertonic left leg. Initial vitals were T\n 97.9, BP 138/83, P 69, RR 24, 99% on NRB (dropping to 99% on 6L by\n NC). Neurology consulted and was concerned this could be a new\n ischemic stroke but the patient also had findings consistent for\n pneumonia and some concerning ECG changes with elevated troponins.\n Given multiple issues this was considered possible CVA versus return of\n previous deficits in the context of other acute illness. Neuro\n recommended no acute management, case was briefly discussed with cards,\n who recommended aspirin, and the patient received levofloxacin and\n cefepime as well as nebs. She was admitted to floor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, Unresponsive\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications\n -----------------------\n ALBUTEROL 2 puffs po three times a day PRN\n BUPROPION HCL 100 mg PO daily\n FLUOXETINE 40 mg PO daily\n HYDROCHLOROTHIAZIDE 25 mg PO daily\n IPRATROPIUM BROMIDE MDI 4 */daily\n LISINOPRIL 5 mg daily\n OMEPRAZOLE 20 mg PO daily\n OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 4*/day PRN\n ACETAMINOPHEN 325-650 mg TID PRN\n DOCUSATE SODIUM 100 mg PO BID\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n -History of right sided MCA ischemic stroke (residual mild left\n hemiparesis)\n -Severe aortic stenosis: TTE showed severe AS and diastolic\n heart failure.\n -Gastric adenocarcinoma s/p partial gastrectomy in \n -Hypertension.\n -Hyperlipidemia.\n -COPD (on 2L supplementary O2 by nasal cannula PRN)\n -Borderline glucose intolerance\n -Osteoporosis.\n -Depression.\n -History of alcohol abuse\n -History of pyloric stenosis.\n Both parents died in their 70's of unclear causes\n Occupation: Retired\n Drugs: None\n Tobacco: 50 pack year smoking history\n Alcohol: History of abuse, none in five years\n Other:\n Review of systems:\n Unobtainable due to obtundation\n Flowsheet Data as of 06:46 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: 85 (84 - 92) bpm\n BP: 118/64(73) {109/63(73) - 118/64(74)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 44.7 kg (admission): 44.7 kg\n Total In:\n 396 mL\n PO:\n TF:\n IVF:\n 396 mL\n Blood products:\n Total out:\n 0 mL\n 55 mL\n Urine:\n 55 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 341 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General Appearance: Thin, cachectic, African American female in mild\n respiratory distress\n Eyes / Conjunctiva: eyes tightly closed and difficult to open, couldn't\n test pupils\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n systolic murmur throughout the precordium\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), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : , Wheezes : occasional, Diminished: ),\n pursed lip breathing\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Cool\n Neurologic: Responds to: Verbal stimuli, Oriented (to): person, ?\n place, Movement: Purposeful, Tone: Decreased, decreased tone in LUE,\n increased tone in left lower extremity, which is internally rotated and\n plantar flexed\n Labs / Radiology\n 327\n 10.4\n 141\n 0.9\n 23\n 32\n 91\n 2.9\n 139\n 33.7\n 9.2\n [image002.jpg]\n Other labs: PT / PTT / INR:14.5/32.6/1.3, CK / CKMB /\n Troponin-T:92/ND/0.47, Differential-Neuts:96, Band:0, Lymph:1, Mono:3,\n Eos:0, Ca++:8.5, Mg++:2.1, PO4:3.3\n Fluid analysis / Other labs: Urinalysis: Trace leuke est, Moderate\n Bili, RBC, WBC, Mod Bact, Neg-Nitrite, 100 Prot\n Imaging: CT Head W/O Contrast (wet read)\n No acute intracranial hemorrhage .Old right temporal infarct.If there\n is\n continued clinical concern for acute ischemia/infarction,recommended\n MRI with\n DWI for further assessment\n Chest Radiograph-Portable AP: (My read)\n Large lung volumes bilaterally with increased lucency consistent with\n bullous disease and emphysema, Some obscuring of the constoprhenic\n angle on the right and apparent infiltrate in right lower lobe\n ECG: ECG reveals irregular rhythm with a rate of 93, possible T wave\n inversions in V1-V3 that are slightly more marked than previously\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, and a previous right\n sided MCA stroke presenting with altered mental status and left sided\n deficits.\n 1) Obtundation/Confusion: Patient's picture is most consistent for\n encephalopathy with waxing and consciousness and responsiveness\n as well as context in general medical illness. Multiple possible\n etiologies for this patient's encephalopathy including most likely\n infection versus CVA versus epileptiform activity versus ACS. We will\n attempt to maximize her status by treating her probable pulmonary\n infection as continuing diagnostic work-up for CVA, epileptic event, or\n cardiac event. Large intracranial hemorrhage ruled out by negative CT\n and large territory ischemic/embolic CVA would likely show some changes\n on CT.\n -Treat pneumonia (see below)\n -MRI/MRA neck of brain to evaluate for stroke, EEG to rule out\n non-convulsive status epilepticus (less likely)\n -Cycle cardiac enzymes\n 2) Community Acquired Bacterial Pneumonia: Patient's daughter reported\n increased cough and respiratory distress at home and there does appear\n to be an infiltrate on chest radiograph. Her oxygen requirement is\n worsened from baseline. Last hospitalization was in and the\n patient lives at home so no particularly high risks for respiratory\n pathogens. Therefore, no clear need for extended coverage. Patient\n received cefepime and levofloxacin in ED but will narrow to just\n levofloxacin unless signs of decompensation or reasons to suspect\n resistant organisms.\n -Levofloxacin 750 mg PO Q48hrs\n -Attempt to obtain sputum cultures if mental status resovles\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Left sided weakness/hypertonicity: These deficits are concerning for\n a new embolic or ischemic stroke (hemorrhagic stroke essentially ruled\n out by CT w/o major deficits). Patient has a history of Aflutter and\n not anticoagulated so always a threat of embolic event. She could also\n have a large ischemic territory though a large event would likely show\n some changes on CT. Other major possibility is that the patient is\n having epileptiform activity perhaps centered around an old area of\n ischemia or that she is simply recapitulating the deficits of her old\n stroke in the context of illness.\n -MRI when possible\n -EEG\n -ASA given possiblity of embolic stroke\n -Would ideally like blood pressure with systolics of 140-160 for brain\n perfusion but this is likely to be impossible to achieve given severe\n AS, will monitor blood pressures and attempt to prevent frank\n hypotension\n 4) Chronic Diastolic Heart Failure/Severe AS: Patient currently\n appearing euvolemic. Will hold home BP meds in context of allowing\n some autoregulation given possiblity of stroke but would be cautious if\n she becomes more hypertensive as this is likely to be poorly tolerated\n given AS.\n -Attempt to keep SBP's between 100-130 monitoring urine output and\n attempting to keep >130\n 5) COPD: Patient appears to have emphysema by exam and radiograph and\n history of COPD. Appears worsened in the context of probable pneumonia\n as oxygen requirement is increased. ABG downstairs relatively benign,\n however, and patient's oxygen requirement has declined.\n -Continue ipratroprium and albuterol\n -recheck ABG later to make sure respiratory alkalosis is not worsening\n -treat pneumonia as above\n -not particularly wheezy now so will hold steroids for the moment (?\n COPD exacerbation) would consider if respiratory status continues to be\n major issue.\n 6) Elevated troponin: Patient's ECG is not impressive for ACS and CK is\n normal suggesting no large territory infarct. She was given aspirin\n downstairs but given threat of stroke that could convert to hemorrhagic\n would be cautious regarding systemic anticoagulation unless further\n evidence. Also will hold BB given concern for low blood pressures and\n hypoperfusion of at risk area of CVA.\n -cycle enzymes, consider BB or systemic anticoagulation if rising CK's\n or hemodynamic instability\n -cardiology aware\n 7) Borderline glucose intolerance: ISS w/ treatment for FSG >200.\n 8) FEN: Very gentle IV fluids given history of AS and dCHF, NPO for now\n given mental status, recheck lytes this PM given Hypokalemia in ED\n (treated)\n 9) PPx: Continue home PPI, SC heparin\n 10) Code: DNR/DNI per daughter confirmed in \n 11) Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2202-09-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 389756, "text": "Chief Complaint: Unresponsiveness/right sided weakness\n HPI:\n This is an 81 year old female with past medical history notable for\n right sided MCA stroke with residual left hemiparesis, COPD, Atrial\n flutter, and partial gastrectomy for gastric cancer who presented to\n the ED today with altered mental status as well as weakness this\n morning. The patient's daughter reports she had been in her normal\n state of health two days ago but yesterday seemed more confused and was\n coughing with an increased O2 requirement. At that time the patient's\n daughter spoke to the patient's PCP . , who recommended\n presentation to the ED for evaluation, the patient refused this however\n and thus stayed at home. This morning the patient was found in bed\n unresponsive and not speaking to her daughter. extremely altered and\n not responding in her normal way to her daughter. In fact she was\n barely responding at all and was unable to stand.\n The patient was brought to the the ED where she was obtunded with\n nonmoving left arm and hypertonic left leg. Initial vitals were T\n 97.9, BP 138/83, P 69, RR 24, 99% on NRB (dropping to 99% on 6L by\n NC). Neurology consulted and was concerned this could be a new\n ischemic stroke but the patient also had findings consistent for\n pneumonia and some concerning ECG changes with elevated troponins.\n Given multiple issues this was considered possible CVA versus return of\n previous deficits in the context of other acute illness. Neuro\n recommended no acute management, case was briefly discussed with cards,\n who recommended aspirin, and the patient received levofloxacin and\n cefepime as well as nebs. She was admitted to floor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, Unresponsive\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications\n -----------------------\n ALBUTEROL 2 puffs po three times a day PRN\n BUPROPION HCL 100 mg PO daily\n FLUOXETINE 40 mg PO daily\n HYDROCHLOROTHIAZIDE 25 mg PO daily\n IPRATROPIUM BROMIDE MDI 4 */daily\n LISINOPRIL 5 mg daily\n OMEPRAZOLE 20 mg PO daily\n OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 4*/day PRN\n ACETAMINOPHEN 325-650 mg TID PRN\n DOCUSATE SODIUM 100 mg PO BID\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n -History of right sided MCA ischemic stroke (residual mild left\n hemiparesis)\n -Severe aortic stenosis: TTE showed severe AS and diastolic\n heart failure.\n -Gastric adenocarcinoma s/p partial gastrectomy in \n -Hypertension.\n -Hyperlipidemia.\n -COPD (on 2L supplementary O2 by nasal cannula PRN)\n -Borderline glucose intolerance\n -Osteoporosis.\n -Depression.\n -History of alcohol abuse\n -History of pyloric stenosis.\n Both parents died in their 70's of unclear causes\n Occupation: Retired\n Drugs: None\n Tobacco: 50 pack year smoking history\n Alcohol: History of abuse, none in five years\n Other:\n Review of systems:\n Unobtainable due to obtundation\n Flowsheet Data as of 06:46 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: 85 (84 - 92) bpm\n BP: 118/64(73) {109/63(73) - 118/64(74)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 44.7 kg (admission): 44.7 kg\n Total In:\n 396 mL\n PO:\n TF:\n IVF:\n 396 mL\n Blood products:\n Total out:\n 0 mL\n 55 mL\n Urine:\n 55 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 341 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General Appearance: Thin, cachectic, African American female in mild\n respiratory distress\n Eyes / Conjunctiva: eyes tightly closed and difficult to open, couldn't\n test pupils\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n systolic murmur throughout the precordium\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), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : , Wheezes : occasional, Diminished: ),\n pursed lip breathing\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Cool\n Neurologic: Responds to: Verbal stimuli, Oriented (to): person, ?\n place, Movement: Purposeful, Tone: Decreased, decreased tone in LUE,\n increased tone in left lower extremity, which is internally rotated and\n plantar flexed\n Labs / Radiology\n 327\n 10.4\n 141\n 0.9\n 23\n 32\n 91\n 2.9\n 139\n 33.7\n 9.2\n [image002.jpg]\n Other labs: PT / PTT / INR:14.5/32.6/1.3, CK / CKMB /\n Troponin-T:92/ND/0.47, Differential-Neuts:96, Band:0, Lymph:1, Mono:3,\n Eos:0, Ca++:8.5, Mg++:2.1, PO4:3.3\n Fluid analysis / Other labs: Urinalysis: Trace leuke est, Moderate\n Bili, RBC, WBC, Mod Bact, Neg-Nitrite, 100 Prot\n Imaging: CT Head W/O Contrast (wet read)\n No acute intracranial hemorrhage .Old right temporal infarct.If there\n is\n continued clinical concern for acute ischemia/infarction,recommended\n MRI with\n DWI for further assessment\n Chest Radiograph-Portable AP: (My read)\n Large lung volumes bilaterally with increased lucency consistent with\n bullous disease and emphysema, Some obscuring of the constoprhenic\n angle on the right and apparent infiltrate in right lower lobe\n ECG: ECG reveals irregular rhythm with a rate of 93, possible T wave\n inversions in V1-V3 that are slightly more marked than previously\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, and a previous right\n sided MCA stroke presenting with altered mental status and left sided\n deficits.\n 1) Obtundation/Confusion: Patient's picture is most consistent for\n encephalopathy with waxing and consciousness and responsiveness\n as well as context in general medical illness. Multiple possible\n etiologies for this patient's encephalopathy including most likely\n infection versus CVA versus epileptiform activity versus ACS. We will\n attempt to maximize her status by treating her probable pulmonary\n infection as continuing diagnostic work-up for CVA, epileptic event, or\n cardiac event. Large intracranial hemorrhage ruled out by negative CT\n and large territory ischemic/embolic CVA would likely show some changes\n on CT.\n -Treat pneumonia (see below)\n -MRI/MRA neck of brain to evaluate for stroke, EEG to rule out\n non-convulsive status epilepticus (less likely)\n -Cycle cardiac enzymes\n 2) Community Acquired Bacterial Pneumonia: Patient's daughter reported\n increased cough and respiratory distress at home and there does appear\n to be an infiltrate on chest radiograph. Her oxygen requirement is\n worsened from baseline. Last hospitalization was in and the\n patient lives at home so no particularly high risks for respiratory\n pathogens. Therefore, no clear need for extended coverage. Patient\n received cefepime and levofloxacin in ED but will narrow to just\n levofloxacin unless signs of decompensation or reasons to suspect\n resistant organisms.\n -Levofloxacin 750 mg PO Q48hrs\n -Attempt to obtain sputum cultures if mental status resovles\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Left sided weakness/hypertonicity: These deficits are concerning for\n a new embolic or ischemic stroke (hemorrhagic stroke essentially ruled\n out by CT w/o major deficits). Patient has a history of Aflutter and\n not anticoagulated so always a threat of embolic event. She could also\n have a large ischemic territory though a large event would likely show\n some changes on CT. Other major possibility is that the patient is\n having epileptiform activity perhaps centered around an old area of\n ischemia or that she is simply recapitulating the deficits of her old\n stroke in the context of illness.\n -MRI when possible\n -EEG\n -ASA given possiblity of embolic stroke\n -Would ideally like blood pressure with systolics of 140-160 for brain\n perfusion but this is likely to be impossible to achieve given severe\n AS, will monitor blood pressures and attempt to prevent frank\n hypotension\n 4) Chronic Diastolic Heart Failure/Severe AS: Patient currently\n appearing euvolemic. Will hold home BP meds in context of allowing\n some autoregulation given possiblity of stroke but would be cautious if\n she becomes more hypertensive as this is likely to be poorly tolerated\n given AS.\n -Attempt to keep SBP's between 100-130 monitoring urine output and\n attempting to keep >130\n 5) COPD: Patient appears to have emphysema by exam and radiograph and\n history of COPD. Appears worsened in the context of probable pneumonia\n as oxygen requirement is increased. ABG downstairs relatively benign,\n however, and patient's oxygen requirement has declined.\n -Continue ipratroprium and albuterol\n -recheck ABG later to make sure respiratory alkalosis is not worsening\n -treat pneumonia as above\n -not particularly wheezy now so will hold steroids for the moment (?\n COPD exacerbation) would consider if respiratory status continues to be\n major issue.\n 6) Elevated troponin: Patient's ECG is not impressive for ACS and CK is\n normal suggesting no large territory infarct. She was given aspirin\n downstairs but given threat of stroke that could convert to hemorrhagic\n would be cautious regarding systemic anticoagulation unless further\n evidence. Also will hold BB given concern for low blood pressures and\n hypoperfusion of at risk area of CVA.\n -cycle enzymes, consider BB or systemic anticoagulation if rising CK's\n or hemodynamic instability\n -cardiology aware\n 7) Borderline glucose intolerance: ISS w/ treatment for FSG >200.\n 8) FEN: Very gentle IV fluids given history of AS and dCHF, NPO for now\n given mental status, recheck lytes this PM given Hypokalemia in ED\n (treated)\n 9) PPx: Continue home PPI, SC heparin\n 10) Code: DNR/DNI per daughter confirmed in \n 11) Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ------ Protected Section ------\n Critical Care\n 81 yo woman with prior CVA, COPD, severe AS and h/o adeno carcinoma adm\n with 2d h/o altered MS finally with obtundation and an increased O2\n requirement. Brought to Ed where altered MS. by Neuro to r/o\n stroke, CXR read as possible PNA adm to ICU. Here 97.5/ 86/ 126/66.\n Pursed lip breathing. Arouses to voice.\n WBC 9.7\n Troponin 0.47\n ECG\n NSSTT changes\n Unclear what precipitated decline. Not much pointing toward infection\n afebrile, nl wbc, CXR unconvincing. Does appear to have had a NSTEMI\n but Trop with suggestive ECG changes but seems unlikely that is what is\n responsible for decline. Her CXR is not convincing but a PNA or flare\n of COPD would be a more likely explanation. Will cover with abx but\n culture and see if we can identify a more convincing site of\n infection.\n DNR/ DNI\n Time spent 45 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 19:41 ------\n" }, { "category": "Nursing", "chartdate": "2202-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390071, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n No c/o sob. No increased work of breathing or respiratory distress\n noted. Lungs cta bilat, diminished at bases.\n Action:\n Oxygen via nasal cannula. Frequent turning and repositioning.\n Response:\n Sats improved. Sat 90 to 96%. Pt remains on 3L via NC.\n Plan:\n Continue to wean from O2 as tolerates.\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be arouseable to voice. Moving all extremities on bed.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2202-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390268, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes spont and to call, not following\n commands, lift\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 389865, "text": "81 yo F with prior CVA, copd, severe AS and h/o adeno carcinoma adm\n with 2 d h/o altered MS and finally obtundation and an increased O2\n requirement, Brought to ED where altered MS. by neuro to r/o\n stroke. CXR read as possible PNA, cardiac enzymes done with Troponin\n .05\n Alteration in Nutrition\n Assessment:\n Pt lethargic, barely arousable,\n Action:\n Pt started on IVF d51/2 with 20 kcl at 75cc/hr, Pt sat up right,\n attempted to arouse and attempted to have pt taken small bite of\n applesauce\n Response:\n Pt did not attempt to take any po intake, po meds held, pt is not awake\n enough to perform speech and swallow but should have consult when more\n alert\n Plan:\n Cont to monitor pt neuro status, schedule speech and swallow when more\n alert, continue with mild fluid rehydration due to cardiac hx\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Ls clear with O2 sats 98% on 4l nc, pt is former smoker., temp\n max 100.4 rectal\n Action:\n Pt turned frequently, antibiotics changed to azithro and ceftriaxone,\n Response:\n Ls remain clear, rr teens, o2 sats 98& on 4l nc,\n Plan:\n Cont with frequent turning etc, wean O2 as tolerated , cont with antb.\n Cxr in am\n Altered mental status (not Delirium)\n Assessment:\n Pt sleeping most of the day, arousable to voice, pt will say her name\n and will respond with\nhome\n if asked where she is , pt answering\n questions with one word sporadically, voice is clear to garbled, perrla\n at 2mm\n Action:\n Eeg done to r/o seizure activity, and repeat MRI done early am,\n Response:\n Eeg negative for seizures, MRI showing atherosclerotic areas as well\n as multi small areas of restricted diffusion r/t embolic source\n Plan:\n Cont with q 4 hr neuro checks , pt to be called out to neuro floor,\n futher work up to determine ? source of infection as reason for ms\n changes\n .H/O cardiac dysrhythmia other\n Assessment:\n Hr 70 sr with pacs and frequent pvc\ns, am k+ 3.5,\n Action:\n Cardiac echo done, K+ repleted with 20 in IVF d51/2 ns\n Response:\n VSS, ? need for follow-up EKG , no further cardiac enzymes ordered.\n Plan:\n Cont to monitor VS, check lytes and replete as needed, if pt remains\n NPO ? starting IV betablocker.\n" }, { "category": "Nursing", "chartdate": "2202-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390269, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes spont and to call, not following\n commands, lifting UE, moving LE to pain, PERL.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2202-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390270, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes spont and to call, not following\n commands, lifting UE, moving LE to pain, PERL.\n Action:\n Neuro checks q4h, oriented to place and time & activities, prior to\n activities.\n Response:\n Responding to verbal commands by turning head, not following commands.\n Plan:\n Cont to monitor, support to patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was on NC 3L, LS clear o2 sat 96-99%\n Action:\n O2 reduced to 2L by NC, HOB >30*, position changed q2h. Mouth care q4h.\n Response:\n O 2sat 94\n 98 %, weak cough, no sputum. LS clear.\n Plan:\n Pulm hygiene,\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 389863, "text": "Alteration in Nutrition\n Assessment:\n Pt lethargic, barely arousable,\n Action:\n Pt started on IVF d51/2 with 20 kcl at 75cc/hr, Pt sat up right,\n attempted to arouse and attempted to have pt taken small bite of\n applesauce\n Response:\n Pt did not attempt to take any po intake, po meds held, pt is not awake\n enough to perform speech and swallow but should have consult when more\n alert\n Plan:\n Cont to monitor pt neuro status, schedule speech and swallow when more\n alert, continue with mild fluid rehydration due to cardiac hx\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Ls clear with O2 sats 98% on 4l nc, pt is former smoker., temp\n max 100.4 rectal\n Action:\n Pt turned frequently, antibiotics changed to azithro and ceftriaxone,\n Response:\n Ls remain clear, rr teens, o2 sats 98& on 4l nc,\n Plan:\n Cont with frequent turning etc, wean O2 as tolerated , cont with antb.\n Cxr in am\n Altered mental status (not Delirium)\n Assessment:\n Pt sleeping most of the day, arousable to voice, pt will say her name\n and will respond with\nhome\n if asked where she is , pt answering\n questions with one word sporadically, voice is clear to garbled, perrla\n at 2mm\n Action:\n Eeg done to r/o seizure activity, and repeat MRI done early am\n Response:\n Eeg negative for seizures, MRI\n Plan:\n .H/O cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390356, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on NC with 1L O2, LS clear and diminished at base, O 2sat\n 90-98%\n Action:\n Chest PT , position changed q2h,\n Response:\n Regular breathing, weak cough productive.\n Plan:\n Cont to monitor, pulm hygiene.\n Alteration in Nutrition\n Assessment:\n Patient is weak and lethargic, awake to call towards morning. Not on TF\n , Pt she is not hungry and \n to eat.\n Action:\n need speech and swallow eval before starting po\ns, mouth care done.\n Response:\n Unchanged.\n Plan:\n ? Speech and swallow eval if pt remains alert and awake during the day\n Altered mental status (not Delirium)\n Assessment:\n Patient is lethargic, opening eyes spont, garbled speech, oriented x1,\n able to say her last name, not aware of place or time.\n Action:\n Q4h neuro checks, reoriented to place and time.\n Response:\n Alert, oriented x1, MAE, PERL, following simple commands.\n Plan:\n Cont to monitor, neuro checks, reorient as needed\n" }, { "category": "Physician ", "chartdate": "2202-09-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 389750, "text": "Chief Complaint: Unresponsiveness/right sided weakness\n HPI:\n This is an 81 year old female with past medical history notable for\n right sided MCA stroke with residual left hemiparesis, COPD, Atrial\n flutter, and partial gastrectomy for gastric cancer who presented to\n the ED today with altered mental status as well as weakness this\n morning. The patient's daughter reports she had been in her normal\n state of health two days ago but yesterday seemed more confused and was\n coughing with an increased O2 requirement. At that time the patient's\n daughter spoke to the patient's PCP . , who recommended\n presentation to the ED for evaluation, the patient refused this however\n and thus stayed at home. This morning the patient was found in bed\n unresponsive and not speaking to her daughter. extremely altered and\n not responding in her normal way to her daughter. In fact she was\n barely responding at all and was unable to stand.\n The patient was brought to the the ED where she was obtunded with\n nonmoving left arm and hypertonic left leg. Initial vitals were T\n 97.9, BP 138/83, P 69, RR 24, 99% on NRB (dropping to 99% on 6L by\n NC). Neurology consulted and was concerned this could be a new\n ischemic stroke but the patient also had findings consistent for\n pneumonia and some concerning ECG changes with elevated troponins.\n Given multiple issues this was considered possible CVA versus return of\n previous deficits in the context of other acute illness. Neuro\n recommended no acute management, case was briefly discussed with cards,\n who recommended aspirin, and the patient received levofloxacin and\n cefepime as well as nebs. She was admitted to floor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, Unresponsive\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications\n -----------------------\n ALBUTEROL 2 puffs po three times a day PRN\n BUPROPION HCL 100 mg PO daily\n FLUOXETINE 40 mg PO daily\n HYDROCHLOROTHIAZIDE 25 mg PO daily\n IPRATROPIUM BROMIDE MDI 4 */daily\n LISINOPRIL 5 mg daily\n OMEPRAZOLE 20 mg PO daily\n OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 4*/day PRN\n ACETAMINOPHEN 325-650 mg TID PRN\n DOCUSATE SODIUM 100 mg PO BID\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n -History of right sided MCA ischemic stroke (residual mild left\n hemiparesis)\n -Severe aortic stenosis: TTE showed severe AS and diastolic\n heart failure.\n -Gastric adenocarcinoma s/p partial gastrectomy in \n -Hypertension.\n -Hyperlipidemia.\n -COPD (on 2L supplementary O2 by nasal cannula PRN)\n -Borderline glucose intolerance\n -Osteoporosis.\n -Depression.\n -History of alcohol abuse\n -History of pyloric stenosis.\n Both parents died in their 70's of unclear causes\n Occupation: Retired\n Drugs: None\n Tobacco: 50 pack year smoking history\n Alcohol: History of abuse, none in five years\n Other:\n Review of systems:\n Constitutional: Unobtainable due to obtundation\n Flowsheet Data as of 06:46 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: 85 (84 - 92) bpm\n BP: 118/64(73) {109/63(73) - 118/64(74)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 44.7 kg (admission): 44.7 kg\n Total In:\n 396 mL\n PO:\n TF:\n IVF:\n 396 mL\n Blood products:\n Total out:\n 0 mL\n 55 mL\n Urine:\n 55 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 341 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General Appearance: Thin, cachectic, African American female in mild\n respiratory distress\n Eyes / Conjunctiva: eyes tightly closed and difficult to open, couldn't\n test pupils\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n systolic murmur throughout the precordium\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), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : , Wheezes : occasional, Diminished: ),\n pursed lip breathing\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Cool\n Neurologic: Responds to: Verbal stimuli, Oriented (to): person, ?\n place, Movement: Purposeful, Tone: Decreased, decreased tone in LUE,\n increased tone in left lower extremity, which is internally rotated and\n plantar flexed\n Labs / Radiology\n 327\n 10.4\n 141\n 0.9\n 23\n 32\n 91\n 2.9\n 139\n 33.7\n 9.2\n [image002.jpg]\n Other labs: PT / PTT / INR:14.5/32.6/1.3, CK / CKMB /\n Troponin-T:92/ND/0.47, Differential-Neuts:96, Band:0, Lymph:1, Mono:3,\n Eos:0, Ca++:8.5, Mg++:2.1, PO4:3.3\n Fluid analysis / Other labs: Urinalysis: Trace leuke est, Moderate\n Bili, RBC, WBC, Mod Bact, Neg-Nitrite, 100 Prot\n Imaging: CT Head W/O Contrast (wet read)\n No acute intracranial hemorrhage .Old right temporal infarct.If there\n is\n continued clinical concern for acute ischemia/infarction,recommended\n MRI with\n DWI for further assessment\n Chest Radiograph-Portable AP: (My read)\n Large lung volumes bilaterally with increased lucency consistent with\n bullous disease and emphysema, Some obscuring of the constoprhenic\n angle on the right and apparent infiltrate in right lower lobe\n ECG: ECG reveals irregular rhythm with a rate of 93, possible T wave\n inversions in V1-V3 that are slightly more marked than previously\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, and a previous right\n sided MCA stroke presenting with altered mental status and left sided\n deficits.\n 1) Obtundation/Confusion: Patient's picture is most consistent for\n encephalopathy with waxing and consciousness and responsiveness\n as well as context in general medical illness. Multiple possible\n etiologies for this patient's encephalopathy including most likely\n infection versus CVA versus epileptiform activity versus ACS. We will\n attempt to maximize her status by treating her probable pulmonary\n infection as continuing diagnostic work-up for CVA, epileptic event, or\n cardiac event. Large intracranial hemorrhage ruled out by negative CT\n and large territory ischemic/embolic CVA would likely show some changes\n on CT.\n -Treat pneumonia (see below)\n -MRI/MRA neck of brain to evaluate for stroke, EEG to rule out\n non-convulsive status epilepticus (less likely)\n -Cycle cardiac enzymes\n 2) Community Acquired Bacterial Pneumonia: Patient's daughter reported\n increased cough and respiratory distress at home and there does appear\n to be an infiltrate on chest radiograph. Her oxygen requirement is\n worsened from baseline. Last hospitalization was in and the\n patient lives at home so no particularly high risks for respiratory\n pathogens. Therefore, no clear need for extended coverage. Patient\n received cefepime and levofloxacin in ED but will narrow to just\n levofloxacin unless signs of decompensation or reasons to suspect\n resistant organisms.\n -Levofloxacin 750 mg PO Q48hrs\n -Attempt to obtain sputum cultures if mental status resovles\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Left sided weakness/hypertonicity: These deficits are concerning for\n a new embolic or ischemic stroke (hemorrhagic stroke essentially ruled\n out by CT w/o major deficits). Patient has a history of Aflutter and\n not anticoagulated so always a threat of embolic event. She could also\n have a large ischemic territory though a large event would likely show\n some changes on CT. Other major possibility is that the patient is\n having epileptiform activity perhaps centered around an old area of\n ischemia or that she is simply recapitulating the deficits of her old\n stroke in the context of illness.\n -MRI when possible\n -EEG\n -ASA given possiblity of embolic stroke\n -Would ideally like blood pressure with systolics of 140-160 for brain\n perfusion but this is likely to be impossible to achieve given severe\n AS, will monitor blood pressures and attempt to prevent frank\n hypotension\n 4) Chronic Diastolic Heart Failure/Severe AS: Patient currently\n appearing euvolemic. Will hold home BP meds in context of allowing\n some autoregulation given possiblity of stroke but would be cautious if\n she becomes more hypertensive as this is likely to be poorly tolerated\n given AS.\n -Attempt to keep SBP's between 100-130 monitoring urine output and\n attempting to keep >130\n 5) COPD: Patient appears to have emphysema by exam and radiograph and\n history of COPD. Appears worsened in the context of probable pneumonia\n as oxygen requirement is increased. ABG downstairs relatively benign,\n however, and patient's oxygen requirement has declined.\n -Continue ipratroprium and albuterol\n -recheck ABG later to make sure respiratory alkalosis is not worsening\n -treat pneumonia as above\n -not particularly wheezy now so will hold steroids for the moment (?\n COPD exacerbation) would consider if respiratory status continues to be\n major issue.\n 6) Elevated troponin: Patient's ECG is not impressive for ACS and CK is\n normal suggesting no large territory infarct. She was given aspirin\n downstairs but given threat of stroke that could convert to hemorrhagic\n would be cautious regarding systemic anticoagulation unless further\n evidence. Also will hold BB given concern for low blood pressures and\n hypoperfusion of at risk area of CVA.\n -cycle enzymes, consider BB or systemic anticoagulation if rising CK's\n or hemodynamic instability\n -cardiology aware\n 7) Borderline glucose intolerance: ISS w/ treatment for FSG >200.\n 8) FEN: Very gentle IV fluids given history of AS and dCHF, NPO for now\n given mental status, recheck lytes this PM given Hypokalemia in ED\n (treated)\n 9) PPx: Continue home PPI, SC heparin\n 10) Code: DNR/DNI per daughter confirmed in \n 11) Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2202-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390163, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes to voice, not following commands, MAE,\n able to lift UE, PERL, moaning most of the time, but denies pain.\n Action:\n Neuro checks q4h, position changed q2h,\n Response:\n Slept for short intervals, unchanged neuro status, sound is garbled,\n not talking ,\n Plan:\n Cont to monitor,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was on a 100% non rebreather earlier, LS clear, O 2sat 90-94%\n Action:\n Changed to hi flow mask with 60% Fio2,\n Response:\n O 2sat remains 90-94% with 60% Fio2,\n Plan:\n Pulm hygiene, wean Fio2 O2 as tolerates.\n" }, { "category": "Nursing", "chartdate": "2202-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 389741, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt with altered mental status, not following commands, flaccid left\n limbs, oriented to self only.\n Action:\n Frequent neuro checks\n Response:\n Unchanged exam\n Plan:\n Possibly for MRI in future.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt with pneumonia, Lung sounds clear to all fields, dry cough.\n A-febrile.\n Action:\n Started on Levofloxacin. 6l nasal canula.\n Response:\n pending\n Plan:\n Close respitory monitoring\n" }, { "category": "Nursing", "chartdate": "2202-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390158, "text": "Altered mental status (not Delirium)\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": "2202-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390246, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert. Opens eyes to voice. Pt moaning in bed, but not speaking.\n Does not follow commands. MAE, lifting and holding bilateral UE.\n PERLL. Denies pain.\n Action:\n Neuro checks q4h.\n Response:\n Neuro status unchanged.\n Plan:\n Neuro checks q4hours. Monitor pt\ns comfort level.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on high flow mask with 40% Fi02. LSCTA. O2 sats low 90\n Action:\n Weaned pt to 3L NC. Nebs as ordered.\n Response:\n O2 sats remained low 90\ns. Respiratory status stable.\n Plan:\n Monitor respiratory status closely.\n" }, { "category": "General", "chartdate": "2202-09-02 00:00:00.000", "description": "ICU Event Note", "row_id": 389832, "text": "Clinician: Attending\n Chief Complaint: Altered Mental Status\n Pneumonia\n CVA\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 MAGNETIC RESONANCE IMAGING - At 05:15 AM--Completed\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\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 09:55 AM\n Vital signs Hemodynamic monitoring Fluid balance 24\n hours Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 103 (72 - 103) bpm\n BP: 127/65(82) {97/47(65) - 156/66(82)} mmHg\n RR: 31 (15 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 45.8 kg (admission): 44.7 kg\n Total In: 2,200 mL 367\n mL\n PO:\n TF:\n IVF: 2,200 mL 367\n mL\n Blood products:\n Total out: 170 mL 155 mL\n Urine: 170 mL 155 mL\n NG:\n Stool:\n Drains:\n Balance: 2,030\n mL 212 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97% ABG: ///35/\n Physical Examination\n General Appearance: Thin\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)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed, not cooperative for\n detailed exam--patient moving both LE extremities\n Labs / Radiology\n 07:20 PM 03:28\n AM\n WBC 9.6\n 12.2\n Hct 28.3\n 30.6\n Plt 247\n 259\n Cr 0.8\n 0.7\n TropT 0.50\n 0.50\n Glucose 119\n 103\n Other labs: PT / PTT / INR:15.8/36.2/1.4, CK / CKMB /\n Troponin-T:91//0.50, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Fluid analysis / Other labs: Patient with CK at 92 throughout and\n Troponin maintained without change.\n Imaging: CT Head--No evidence of acute stroke seen\n MRI-Multiple small acute infarcts in right and left MCA distribution.\n CXR-Significnat rotation--widened mediastinum suggested on film but\n does correlate with rotation.\n ECG: -Patient with anterior ST segment depression and suggestion of\n lateral Q-waves noted but no acute ST segment elevations.\n Assessment and Plan\n 81 yo female presenting with history concerning for pneumonia and with\n evolution of unresponsiveness and now found to have new left sided\n weakness concerning for new CVA and in the setting of elevation in\n troponin patient to MICU for further care. Her findings in regards to\n focal deficits are concerning for new acute insult but do raise the\n question of possible evolution of symptoms with previous deficits.\n Important to note is that patient does have a history of atrial flutter\n as defined on the previous ECG's. The presentation with altered mental\n status now with diffuse cortical insults now with significant concern\n for embolic events.\n 1)CVA-She has no evidence of preliminary report of ongoing seizure\n activity. We do have multiple diffuse cortical insults concerning for\n embolic events. This in the setting of troponin elevation does raise\n the question of new cardiac insult or arrhythmia driving clinical\n presentation.\n -Will continue with neurology input\n -Will treat with ASA and evaluate with TTE for concern for persistent\n clot and extent and severity of Aortic Stenosis\n -Will need to maintain on telemetry with concern for recurrent\n arrhythmia\n -Will follow up on neck imaging to consider need for ultrasound\n 2)Pneumonia-This is primarily driven by clinical history and altered\n mental status and concern for aspiration is significant\n -CTX/Azithro to continue\n -sputum GS C+S with possible yield and will follow it\n -Follow fever and respiratory distress\n -She maintains mild resting tachypnea\n 3)Troponin Elevation-This is seen in the setting of CVA and normal CK\n seen. ECG does not show acute ST segment elevations and T-wave changes\n are possibly driven by cerebral T-waves.\n -Follow CK and telemetry\n -Follow ECG\n 4)Altered Mental Status-\n -Attributable to all of the above\n ICU Care\n Nutrition: NPO\nmaintenancy fluids\n Glycemic Control:\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Will need to confirm code status with\n daughter and will remain full code until that discussion is completed\n Code status: Full code\n Disposition :ICU\n Total time spent: 37 minutes\n Total time spent: 37 minutes\n" }, { "category": "Physician ", "chartdate": "2202-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 389840, "text": "Chief Complaint: 81 yof with PMH of right sided MCA ischemic stroke\n with residual left hemiparesis, COPD, Aflutter and partial gastrectomy\n for gastric cancer a/w altered mental status, concern for stroke,\n concern for AMI/NSTEMI and concern for pneumonia. Patient is DNR/DNI\n confirmed by family.\n 24 Hour Events:\n - no acute overnight events\n - patient given minimal fluids, oxygen requirement was weaned to 4L,\n patient underwent MR of head\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\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 07:26 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: 36.3\nC (97.3\n HR: 80 (72 - 92) bpm\n BP: 156/56(72) {97/47(65) - 156/66(78)} mmHg\n RR: 18 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.8 kg (admission): 44.7 kg\n Total In:\n 2,200 mL\n 344 mL\n PO:\n TF:\n IVF:\n 2,200 mL\n 344 mL\n Blood products:\n Total out:\n 170 mL\n 132 mL\n Urine:\n 170 mL\n 132 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,030 mL\n 212 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///35/\n Physical Examination\n General: alert, responsive, disoriented to time and place\n Lungs: CTAB no WRR\n Heart: RRR, no MRG\n Abdomen: soft NTND\n Extremities: NT, no CCE, DP 2+\n Labs / Radiology\n 259 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 100 mEq/L\n 139 mEq/L\n 30.6 %\n 12.2 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n WBC\n 9.6\n 12.2\n Hct\n 28.3\n 30.6\n Plt\n 247\n 259\n Cr\n 0.8\n 0.7\n TropT\n 0.50\n 0.50\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:15.8/36.2/1.4, CK / CKMB /\n Troponin-T:91//0.50, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Microbiology\n - urine \n pending\n - blood 10/7\n pending\n Imaging\n - CXR \n small right pleural effusion with overlying atelectasis\n Assessment and Plan\n 81 yof with multiple medical problems including diastolic HF with\n severe aortic stensosis, atrial flutter not on anti-coagulation, COPD\n and prior right sided MCA ischemic stroke presenting with altered MS\n and left sided deficits.\n # Altered Mental Status / Confusion: per daughter, this is an acute\n change from her prior baseline with focal left sided deficits c/w prior\n right sided MCA CVA. Possible etiologies of altered mental status\n include infection, metabolic derangement, stroke, seizure in territory\n of prior CVA. Patient also with serially elevated TN\ns c/w prior\n myocardial infarction\n NSTEMI.\n - f/u pancultures\n urine, blood\n - serial CXR to evaluate development of RLL infiltrate\n - f/u MRI/MRA neck brain to evaluate for new infarct\n - f/u EEG to rule out subclinical status in territory of prior CVA\n eliciting focal neurological signs\n - would treat at this point for presumed PNA given reported increased\n cough, abnormal appearing CXR a/w with MS change\n # Presume CAP: patient presented with AMS change with recent history\n of increasing respiratory distress and cough and possible infiltrate on\n CXR. Although imaging and clinical exam is not convincing, her history\n and association with MS empiric treatment..\n - switch to ceftriaxone and azithromycin for CAP as levoquin can alter\n mental status in elderly\n - titrate O2 requirements to comfort\n - follow serial CXR, fever curve, WBC\n # Left sided weakness/hypertonicity: focal neurological deficits\n concerning for repeat CVA vs. seizure (subclinical status).\n - f/u MRI read\n - f/u EEG report\n - f/u neuro recommendations pending the above information\n - continue ASA in setting of NSTEMI and possibility of embolic CVA in\n setting of AFlutter\n # Chronic Diastolic Heart Failure/Severe AS: patient currently appears\n euvolemic or dry\n - start maintenance fluids but avoid aggressive fluid resuscitation in\n setting severe AS and risk of pulmonary flash\n # COPD: decreasing oxygen requirement but history of cough, sputum\n production and shortness of breath also c/w COPD exacerbation.\n - continue ipratroprium and albuterol nebs\n - treat pneumonia as above\n # Elevated troponin: ECG not suggestive of myocardial ischemia however\n cardiac enzymes suggestive of myocardial injury. This may suggest\n prior MI in recent days given q waves on ECG and plateaud troponins.\n This may also be c/w NSTEMI.\n - continue ASA\n - hold anticoagulation for concern of CVA\n - holding BB as patient is NPO, normotensive and r/o dropping pressure\n outweighs immediate cardiovascular benefit\n # FEN: maintenance fluids, NPO with SS consult\n # PPx: Continue home PPI, SC heparin\n # Code: DNR/DNI per daughter confirmed in \n # Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390041, "text": "Chief Complaint:\n 24 Hour Events:\n - Pt briefly became short of breath, responded to 2mg morphine and\n nebs.\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 01:04 PM\n Azithromycin - 10:13 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:30 PM\n Enoxaparin (Lovenox) - 08:00 PM\n Metoprolol - 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 08:20 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: 36.7\nC (98.1\n HR: 83 (69 - 108) bpm\n BP: 123/60(77) {94/52(64) - 125/67(82)} mmHg\n RR: 19 (13 - 25) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 47.5 kg (admission): 44.7 kg\n Total In:\n 580 mL\n 82 mL\n PO:\n TF:\n IVF:\n 330 mL\n 82 mL\n Blood products:\n Total out:\n 74 mL\n 96 mL\n Urine:\n 74 mL\n 96 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -14 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///24/\n Physical Examination\n Cardiovascular: Gen: NAD able to respond to simple commands\n CV: RRR, Nl S1 and S2\n Resp: bibasilar crackles\n Abd: soft, NT, ND ABS\n Ext: no c/c/e\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 333 K/uL\n 9.2 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 5.5 mEq/L\n 25 mg/dL\n 102 mEq/L\n 138 mEq/L\n 30.1 %\n 14.3 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n WBC\n 9.6\n 12.2\n 14.3\n Hct\n 28.3\n 30.6\n 30.1\n Plt\n 247\n 259\n 333\n Cr\n 0.8\n 0.7\n 0.8\n TropT\n 0.50\n 0.50\n 0.55\n 0.75\n Glucose\n 119\n 103\n 134\n Other labs: PT / PTT / INR:17.4/40.2/1.6, CK / CKMB /\n Troponin-T:87/8/0.75, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\n Imaging: CXR : No acute cardiopulmonary findings. Hyperinflation\n consistent with\n COPD. Mild bibasilar fibrosis is unchanged.\n Microbiology: urine, blood cultures pending.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission. Flat CKs suggest troponin elevation either from stroke or\n more remote cardiac event.\n - continue to provide supportive measures s/p stroke\n - treat pneumonia as below\n - hold\n 2) Increased Cough/O2 Requirement: Possible pneumonia\n (community-aquired), vs COPD flare.\n - sputum cultures\n -CTX/Azithromycin to complete 7 day course\n -Continue ipratroprium and albuterol\n -methylprednisolone\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS/Elevated\n Troponin/Aflutter/HTN: Since last ECHO pt has deterioriating cardiac\n status with increased Aortic insufficiency and RV hypokinesis. ekg may\n have worrisome signs with pseudonormalization of T waves. Flat CKs\n suggest troponin elevation may be from remote cardiac event. ECHO\n suggest completed infarct. Concerned that pt stroke was from a\n showering of cardiac emboli.\n - hold lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - no anticoagulation given risk\n - cont aspirin 81 mg daily\n - lopressor 5mg IV q6h\n .\n 4)elevated lactate: potentially be from increased work of\n breathing. Is normotensive making septic shock unlikely.\n -continue antibiotics\n -oxygen supplementation\n 5)multiple cerebral infarcts: lovenox 40mg . sourc of emboli has\n not been found.\n 4) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 5) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - please check iron studies, B12, folate as pt may need all of these\n repleted. If B12 is low pls give IM injection.\n 6) Leukocytosis: neg Urine cx, benign abd exam, on CTX/azithro to\n complete Community Aquired PNA course. also be reactive in setting\n of multiple acute strokes.\n - trend and culture pt (sputum, CXR, UA, stool for c. diff) if spikes\n temp <95 for > 100.5\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390042, "text": "Chief Complaint: Respiratory failure, CHF, , delerium\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 Delerium not improved overnight\n 24 Hour Events:\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 01:04 PM\n Azithromycin - 10:13 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:30 PM\n Enoxaparin (Lovenox) - 08:00 PM\n Metoprolol - 12:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: Delirious\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:48 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: 36.7\nC (98.1\n HR: 84 (69 - 108) bpm\n BP: 112/65(77) {94/52(64) - 125/67(82)} mmHg\n RR: 18 (13 - 25) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 47.5 kg (admission): 44.7 kg\n Total In:\n 580 mL\n 95 mL\n PO:\n TF:\n IVF:\n 330 mL\n 95 mL\n Blood products:\n Total out:\n 74 mL\n 108 mL\n Urine:\n 74 mL\n 108 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -13 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 333 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 5.5 mEq/L\n 25 mg/dL\n 102 mEq/L\n 138 mEq/L\n 30.1 %\n 14.3 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n WBC\n 9.6\n 12.2\n 14.3\n Hct\n 28.3\n 30.6\n 30.1\n Plt\n 247\n 259\n 333\n Cr\n 0.8\n 0.7\n 0.8\n TropT\n 0.50\n 0.50\n 0.55\n 0.75\n Glucose\n 119\n 103\n 134\n Other labs: PT / PTT / INR:17.4/40.2/1.6, CK / CKMB /\n Troponin-T:87/8/0.75, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Continues to be encephalopathic --> suspect\n delerium in setting of systemic illness. Leukocytosis lower today.\n 2) Increased Cough/O2 Requirement: Treating for CAP with azithro and\n CTX. Getting steroid course for COPD\n 3) CHF: very BNP despite relatively normal looking CXR (though\n emphysema makes interpretation difficult). Has aortic stenosis as well\n as hypokinetic LV\n 4)elevated lactate: potentially be from increased work of\n breathing. Is normotensive making septic shock unlikely.\n -continue antibiotics\n -oxygen supplementation\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments: Need to have further discussion with daughter\n re: goals of care\n Code status: DNI (do not intubate)\n Disposition :\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2202-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 389801, "text": "Chief Complaint: 81 yof with PMH of right sided MCA ischemic stroke\n with residual left hemiparesis, COPD, Aflutter and partial gastrectomy\n for gastric cancer a/w altered mental status, concern for stroke,\n concern for AMI/NSTEMI and concern for pneumonia. Patient is DNR/DNI\n confirmed by family.\n 24 Hour Events:\n - No acute overnight events\n - Patient given gentle fluids, oxygen requirement weaned and patient\n underwent MR of head\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\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 07:26 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: 36.3\nC (97.3\n HR: 80 (72 - 92) bpm\n BP: 156/56(72) {97/47(65) - 156/66(78)} mmHg\n RR: 18 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.8 kg (admission): 44.7 kg\n Total In:\n 2,200 mL\n 344 mL\n PO:\n TF:\n IVF:\n 2,200 mL\n 344 mL\n Blood products:\n Total out:\n 170 mL\n 132 mL\n Urine:\n 170 mL\n 132 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,030 mL\n 212 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///35/\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 259 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 100 mEq/L\n 139 mEq/L\n 30.6 %\n 12.2 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n WBC\n 9.6\n 12.2\n Hct\n 28.3\n 30.6\n Plt\n 247\n 259\n Cr\n 0.8\n 0.7\n TropT\n 0.50\n 0.50\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:15.8/36.2/1.4, CK / CKMB /\n Troponin-T:91//0.50, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Microbiology\n - urine \n pending\n - blood 10/7\n pending\n Imaging\n - CXR \n small right pleural effusion with overlying atelectasis\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, and a previous right\n sided MCA stroke presenting with altered mental status and left sided\n deficits.\n Obtundation/Confusion: Patient's picture is most consistent for\n encephalopathy with waxing and consciousness and responsiveness\n as well as context in general medical illness. Multiple possible\n etiologies for this patient's encephalopathy including most likely\n infection versus CVA versus epileptiform activity versus ACS. We will\n attempt to maximize her status by treating her probable pulmonary\n infection as continuing diagnostic work-up for CVA, epileptic event, or\n cardiac event. Large intracranial hemorrhage ruled out by negative CT\n and large territory ischemic/embolic CVA would likely show some changes\n on CT.\n -Treat pneumonia (see below)\n -MRI/MRA neck of brain to evaluate for stroke, EEG to rule out\n non-convulsive status epilepticus (less likely)\n -Cycle cardiac enzymes\n 2) Community Acquired Bacterial Pneumonia: Patient's daughter reported\n increased cough and respiratory distress at home and there does appear\n to be an infiltrate on chest radiograph. Her oxygen requirement is\n worsened from baseline. Last hospitalization was in and the\n patient lives at home so no particularly high risks for respiratory\n pathogens. Therefore, no clear need for extended coverage. Patient\n received cefepime and levofloxacin in ED but will narrow to just\n levofloxacin unless signs of decompensation or reasons to suspect\n resistant organisms.\n -Levofloxacin 750 mg PO Q48hrs\n -Attempt to obtain sputum cultures if mental status resovles\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Left sided weakness/hypertonicity: These deficits are concerning for\n a new embolic or ischemic stroke (hemorrhagic stroke essentially ruled\n out by CT w/o major deficits). Patient has a history of Aflutter and\n not anticoagulated so always a threat of embolic event. She could also\n have a large ischemic territory though a large event would likely show\n some changes on CT. Other major possibility is that the patient is\n having epileptiform activity perhaps centered around an old area of\n ischemia or that she is simply recapitulating the deficits of her old\n stroke in the context of illness.\n -MRI when possible\n -EEG\n -ASA given possiblity of embolic stroke\n -Would ideally like blood pressure with systolics of 140-160 for brain\n perfusion but this is likely to be impossible to achieve given severe\n AS, will monitor blood pressures and attempt to prevent frank\n hypotension\n 4) Chronic Diastolic Heart Failure/Severe AS: Patient currently\n appearing euvolemic. Will hold home BP meds in context of allowing\n some autoregulation given possiblity of stroke but would be cautious if\n she becomes more hypertensive as this is likely to be poorly tolerated\n given AS.\n -Attempt to keep SBP's between 100-130 monitoring urine output and\n attempting to keep >130\n 5) COPD: Patient appears to have emphysema by exam and radiograph and\n history of COPD. Appears worsened in the context of probable pneumonia\n as oxygen requirement is increased. ABG downstairs relatively benign,\n however, and patient's oxygen requirement has declined.\n -Continue ipratroprium and albuterol\n -recheck ABG later to make sure respiratory alkalosis is not worsening\n -treat pneumonia as above\n -not particularly wheezy now so will hold steroids for the moment (?\n COPD exacerbation) would consider if respiratory status continues to be\n major issue.\n 6) Elevated troponin: Patient's ECG is not impressive for ACS and CK is\n normal suggesting no large territory infarct. She was given aspirin\n downstairs but given threat of stroke that could convert to hemorrhagic\n would be cautious regarding systemic anticoagulation unless further\n evidence. Also will hold BB given concern for low blood pressures and\n hypoperfusion of at risk area of CVA.\n -cycle enzymes, consider BB or systemic anticoagulation if rising CK's\n or hemodynamic instability\n -cardiology aware\n 7) Borderline glucose intolerance: ISS w/ treatment for FSG >200.\n 8) FEN: Very gentle IV fluids given history of AS and dCHF, NPO for now\n given mental status, recheck lytes this PM given Hypokalemia in ED\n (treated)\n 9) PPx: Continue home PPI, SC heparin\n 10) Code: DNR/DNI per daughter confirmed in \n 11) Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390051, "text": "Chief Complaint:\n 24 Hour Events:\n - Pt briefly became short of breath, responded to 2mg morphine and\n nebs.\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 01:04 PM\n Azithromycin - 10:13 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:30 PM\n Enoxaparin (Lovenox) - 08:00 PM\n Metoprolol - 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 08:20 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: 36.7\nC (98.1\n HR: 83 (69 - 108) bpm\n BP: 123/60(77) {94/52(64) - 125/67(82)} mmHg\n RR: 19 (13 - 25) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 47.5 kg (admission): 44.7 kg\n Total In:\n 580 mL\n 82 mL\n PO:\n TF:\n IVF:\n 330 mL\n 82 mL\n Blood products:\n Total out:\n 74 mL\n 96 mL\n Urine:\n 74 mL\n 96 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -14 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///24/\n Physical Examination\n Cardiovascular: Gen: NAD able to respond to simple commands\n CV: RRR, Nl S1 and S2\n Resp: bibasilar crackles\n Abd: soft, NT, ND ABS\n Ext: no c/c/e\n Labs / Radiology\n 333 K/uL\n 9.2 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 5.5 mEq/L\n 25 mg/dL\n 102 mEq/L\n 138 mEq/L\n 30.1 %\n 14.3 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n WBC\n 9.6\n 12.2\n 14.3\n Hct\n 28.3\n 30.6\n 30.1\n Plt\n 247\n 259\n 333\n Cr\n 0.8\n 0.7\n 0.8\n TropT\n 0.50\n 0.50\n 0.55\n 0.75\n Glucose\n 119\n 103\n 134\n Other labs: PT / PTT / INR:17.4/40.2/1.6, CK / CKMB /\n Troponin-T:87/8/0.75, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\n Imaging: CXR : No acute cardiopulmonary findings. Hyperinflation\n consistent with\n COPD. Mild bibasilar fibrosis is unchanged.\n Microbiology: urine, blood cultures pending.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission. Flat CKs suggest troponin elevation either from stroke or\n more remote cardiac event.\n - continue to provide supportive measures s/p stroke\n - treat pneumonia as below\n 2) Increased Cough/O2 Requirement: Possible pneumonia\n (community-aquired), vs COPD flare.\n - sputum cultures\n -CTX/Azithromycin to complete 7 day course\n -Continue ipratroprium and albuterol\n -methylprednisolone\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS/Elevated\n Troponin/Aflutter/HTN: Since last ECHO pt has deterioriating cardiac\n status with increased Aortic insufficiency and RV hypokinesis. ekg may\n have worrisome signs with pseudonormalization of T waves. Flat CKs\n suggest troponin elevation may be from remote cardiac event. ECHO\n suggest completed infarct. Concerned that pt stroke was from a\n showering of cardiac emboli.\n - hold lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - on lovenox \n - cont aspirin 81 mg daily\n - lopressor 5mg IV q6h\n .\n 4)elevated lactate: potentially be from increased work of\n breathing. Is normotensive making septic shock unlikely.\n -continue antibiotics\n -oxygen supplementation\n 5)multiple cerebral infarcts: lovenox 40mg . sourc of emboli has\n not been found.\n 4) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 5) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - f/u iron studies, b12, folate\n 6) Leukocytosis: neg Urine cx, benign abd exam, on CTX/azithro to\n complete Community Aquired PNA course. also be reactive in setting\n of multiple acute strokes.\n - trend and culture pt (sputum, CXR, UA, stool for c. diff) if spikes\n temp <95 for > 100.5\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2202-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390148, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt more alert today. Sats in mid to high 90\ns on 3l.\n Action:\n Close respiratory assessment.\n Response:\n As shift progressed patient noted to desaturationing. Sats maintaining\n in the mid 80\n MICU notified. Pt put on face tent at 70% with\n minimal effect. Dr from MICU present\n pt ordered for 100% NRB\n and 2MG ivp morphine. Abg sent by resident. Ck\ns sent and to be\n cycled. Sats acceptable on 100% NRB - of O2 pt desats to low 80\n Abg acceptable.\n Plan:\n Wean from O2 as tolerates and appropriate. Monitor respiratory\n status. Strict i/o\ns assess for fluid overload.\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert this a.m. Opening eyes to voice. Answering simple\n questions. Voice garbled, however patient without dentures. Pt able\n to lift and hold upper extremities\n moving lower extremities on bed.\n Action:\n Close neuro assessment done.\n Response:\n Pt slightly lethargic post morphine, however pupils remain reactive and\n continues to move extremities on bed.\n Plan:\n Cont close neuro assessment. Monitor for stroke or bleed.\n" }, { "category": "Physician ", "chartdate": "2202-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 389811, "text": "Chief Complaint: 81 yof with PMH of right sided MCA ischemic stroke\n with residual left hemiparesis, COPD, Aflutter and partial gastrectomy\n for gastric cancer a/w altered mental status, concern for stroke,\n concern for AMI/NSTEMI and concern for pneumonia. Patient is DNR/DNI\n confirmed by family.\n 24 Hour Events:\n - no acute overnight events\n - patient given minimal fluids, oxygen requirement was weaned to 4L,\n patient underwent MR of head\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\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 07:26 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: 36.3\nC (97.3\n HR: 80 (72 - 92) bpm\n BP: 156/56(72) {97/47(65) - 156/66(78)} mmHg\n RR: 18 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.8 kg (admission): 44.7 kg\n Total In:\n 2,200 mL\n 344 mL\n PO:\n TF:\n IVF:\n 2,200 mL\n 344 mL\n Blood products:\n Total out:\n 170 mL\n 132 mL\n Urine:\n 170 mL\n 132 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,030 mL\n 212 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///35/\n Physical Examination\n General: alert, responsive, disoriented to time and place\n Lungs: CTAB no WRR\n Heart: RRR, no MRG\n Abdomen: soft NTND\n Extremities: NT, no CCE, DP 2+\n Labs / Radiology\n 259 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 100 mEq/L\n 139 mEq/L\n 30.6 %\n 12.2 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n WBC\n 9.6\n 12.2\n Hct\n 28.3\n 30.6\n Plt\n 247\n 259\n Cr\n 0.8\n 0.7\n TropT\n 0.50\n 0.50\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:15.8/36.2/1.4, CK / CKMB /\n Troponin-T:91//0.50, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Microbiology\n - urine \n pending\n - blood 10/7\n pending\n Imaging\n - CXR \n small right pleural effusion with overlying atelectasis\n Assessment and Plan\n 81 yof with multiple medical problems including diastolic HF with\n severe aortic stensosis, atrial flutter not on anti-coagulation, COPD\n and prior right sided MCA ischemic stroke presenting with altered MS\n and left sided deficits.\n # Altered Mental Status / Confusion: per daughter, this is an acute\n change from her prior baseline with focal left sided deficits c/w prior\n right sided MCA CVA. Possible etiologies of altered mental status\n include infection, metabolic derangement, stroke, seizure in territory\n of prior CVA. Patient also with serially elevated TN\ns c/w myocardial\n infarction\n NSTEMI.\n - f/u pancultures\n urine, blood\n - serial CXR to evaluate development of RLL infiltrate\n - f/u MRI/MRA neck brain to evaluate for new infarct\n - f/u EEG to rule out subclinical status in territory of prior CVA\n eliciting focal neurological signs\n - would treat at this point for presumed PNA given reported increased\n cough, abnormal appearing CXR a/w with MS change\n # Presume CAP: patient presented with AMS change with recent history\n of increasing respiratory distress and cough and possible infiltrate on\n CXR. Although imaging and clinical exam is not convincing, her history\n and association with MS empiric treatment..\n - continue levofloxacin for CAP\n - titrate O2 requirements to comfort\n - follow serial CXR, fever curve, WBC\n # Left sided weakness/hypertonicity: focal neurological deficits\n concerning for repeat CVA vs. seizure (subclinical status).\n - f/u MRI read\n - f/u EEG report\n - f/u neuro recommendations pending the above information\n - continue ASA in setting of NSTEMI and possibility of embolic CVA in\n setting of AFlutter\n # Chronic Diastolic Heart Failure/Severe AS: patient currently appears\n euvolemic or dry\n - avoid aggressive fluid resuscitation in setting severe AS and risk\n Patient currently appearing euvolemic. Will hold home BP meds in\n context of allowing some autoregulation given possiblity of stroke but\n would be cautious if she becomes more hypertensive as this is likely to\n be poorly tolerated given AS.\n -Attempt to keep SBP's between 100-130 monitoring urine output and\n attempting to keep >130\n 5) COPD: Patient appears to have emphysema by exam and radiograph and\n history of COPD. Appears worsened in the context of probable pneumonia\n as oxygen requirement is increased. ABG downstairs relatively benign,\n however, and patient's oxygen requirement has declined.\n -Continue ipratroprium and albuterol\n -recheck ABG later to make sure respiratory alkalosis is not worsening\n -treat pneumonia as above\n -not particularly wheezy now so will hold steroids for the moment (?\n COPD exacerbation) would consider if respiratory status continues to be\n major issue.\n 6) Elevated troponin: Patient's ECG is not impressive for ACS and CK is\n normal suggesting no large territory infarct. She was given aspirin\n downstairs but given threat of stroke that could convert to hemorrhagic\n would be cautious regarding systemic anticoagulation unless further\n evidence. Also will hold BB given concern for low blood pressures and\n hypoperfusion of at risk area of CVA.\n -cycle enzymes, consider BB or systemic anticoagulation if rising CK's\n or hemodynamic instability\n -cardiology aware\n 7) Borderline glucose intolerance: ISS w/ treatment for FSG >200.\n 8) FEN: Very gentle IV fluids given history of AS and dCHF, NPO for now\n given mental status, recheck lytes this PM given Hypokalemia in ED\n (treated)\n 9) PPx: Continue home PPI, SC heparin\n 10) Code: DNR/DNI per daughter confirmed in \n 11) Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390123, "text": "Chief Complaint:\n 24 Hour Events:\n - Pt briefly became short of breath, responded to 2mg morphine and\n nebs.\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:00 PM\n Metoprolol - 06:00 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 08:25 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: 36.1\nC (96.9\n HR: 76 (71 - 84) bpm\n BP: 139/73(89) {94/49(68) - 139/94(103)} mmHg\n RR: 15 (14 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50 kg (admission): 44.7 kg\n Total In:\n 340 mL\n 50 mL\n PO:\n TF:\n IVF:\n 340 mL\n 50 mL\n Blood products:\n Total out:\n 265 mL\n 80 mL\n Urine:\n 265 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -30 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 364 K/uL\n 9.7 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 35 mg/dL\n 104 mEq/L\n 143 mEq/L\n 32.3 %\n 15.8 K/uL\n [image002.jpg]\n 07:20 PM\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n WBC\n 9.6\n 12.2\n 14.3\n 15.8\n Hct\n 28.3\n 30.6\n 30.1\n 32.3\n Plt\n 247\n 259\n 333\n 364\n Cr\n 0.8\n 0.7\n 0.8\n 0.9\n TropT\n 0.50\n 0.50\n 0.55\n 0.75\n 0.72\n Glucose\n 119\n 103\n 134\n 119\n Other labs: PT / PTT / INR:18.3/33.9/1.7, CK / CKMB /\n Troponin-T:87/8/0.72, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission. Flat CKs suggest troponin elevation either from stroke or\n more remote cardiac event.\n - continue to provide supportive measures s/p stroke (maintaining BPs)\n - treat pneumonia as below\n 2) Increased Cough/O2 Requirement: Possible pneumonia\n (community-aquired), vs COPD flare.\n - sputum cultures\n -CTX/Azithromycin to complete 7 day course\n -Continue ipratroprium and albuterol\n -methylprednisolone\n -Titrate oxygen to comfort and O2 sat between 92-94%\n -doesnt appear volume overloaded\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS/Elevated\n Troponin/Aflutter/HTN: Since last ECHO pt has deterioriating cardiac\n status with increased Aortic insufficiency and RV hypokinesis. ekg may\n have worrisome signs with pseudonormalization of T waves. Flat CKs\n suggest troponin elevation may be from remote cardiac event. ECHO\n suggest completed infarct. Concerned that pt stroke was from a\n showering of cardiac emboli.\n - hold lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - on lovenox \n - cont aspirin 81 mg daily\n - lopressor 5mg IV q6h\n .\n 4)elevated lactate: potentially be from increased work of\n breathing. Is normotensive making septic shock unlikely.\n -continue antibiotics\n -oxygen supplementation\n 3)multiple cerebral infarcts: lovenox 40mg . sourc of emboli has\n not been found.\n 4) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 5) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - f/u iron studies, b12, folate\n 6) Leukocytosis: neg Urine cx, benign abd exam, on CTX/azithro to\n complete Community Aquired PNA course. also be reactive in setting\n of multiple acute strokes.\n - trend and culture pt (sputum, CXR, UA, stool for c. diff) if spikes\n temp <95 for > 100.5\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2202-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390150, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt more alert today. Sats in mid to high 90\ns on 3l.\n Action:\n Close respiratory assessment.\n Response:\n As shift progressed patient noted to desaturationing. Sats maintaining\n in the mid 80\n MICU notified. Pt put on face tent at 70% with\n minimal effect. Dr from MICU present\n pt ordered for 100% NRB\n and 2MG ivp morphine. Abg sent by resident. Ck\ns sent and to be\n cycled. Sats acceptable on 100% NRB - of O2 pt desats to low 80\n Abg acceptable.\n Plan:\n Wean from O2 as tolerates and appropriate. Monitor respiratory\n status. Strict i/o\ns assess for fluid overload.\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert this a.m. Opening eyes to voice. Answering simple\n questions. Voice garbled, however patient without dentures. Pt able\n to lift and hold upper extremities\n moving lower extremities on bed.\n Action:\n Close neuro assessment done.\n Response:\n Pt slightly lethargic post morphine, however pupils remain reactive and\n continues to move extremities on bed.\n Plan:\n Cont close neuro assessment. Monitor for stroke or bleed.\n" }, { "category": "Nutrition", "chartdate": "2202-09-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 390233, "text": "Subjective\n Patient w/ AMS\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 44.7 kg\n 46.7 kg ( 12:00 AM)\n Fluid shifts\n 19.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 98%\n Not applicable\n Not available\n Diagnosis: PNA\n PMHx:\n History of right sided MCA ischemic stroke (residual mild left\n hemiparesis)\n -Severe aortic stenosis: TTE showed severe AS and diastolic\n heart failure.\n -Gastric adenocarcinoma s/p partial gastrectomy in \n -Hypertension.\n -Hyperlipidemia.\n -COPD (on 2L supplementary O2 by nasal cannula PRN)\n -Borderline glucose intolerance\n -Osteoporosis.\n -Depression.\n -History of alcohol abuse\n -History of pyloric stenosis.\n Food allergies and intolerances: None per POE\n Pertinent medications: HISS, omeprazole, MVI, Ceftriaxone, asa,\n azithromycin, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 05:09 AM\n Glucose Finger Stick\n 177\n 10:00 AM\n BUN\n 45 mg/dL\n 05:09 AM\n Creatinine\n 1.0 mg/dL\n 05:09 AM\n Sodium\n 143 mEq/L\n 05:09 AM\n Potassium\n 5.5 mEq/L\n 05:09 AM\n Chloride\n 105 mEq/L\n 05:09 AM\n TCO2\n 29 mEq/L\n 05:09 AM\n PO2 (arterial)\n 103 mm Hg\n 03:32 PM\n PCO2 (arterial)\n 36 mm Hg\n 03:32 PM\n pH (arterial)\n 7.52 units\n 03:32 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:32 PM\n Calcium non-ionized\n 9.0 mg/dL\n 03:07 AM\n Phosphorus\n 2.6 mg/dL\n 03:07 AM\n Magnesium\n 2.0 mg/dL\n 03:07 AM\n ALT\n 18 IU/L\n 03:31 AM\n Alkaline Phosphate\n 127 IU/L\n 03:31 AM\n AST\n 42 IU/L\n 03:31 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:31 AM\n WBC\n 17.9 K/uL\n 05:09 AM\n Hgb\n 9.8 g/dL\n 05:09 AM\n Hematocrit\n 32.7 %\n 05:09 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/ (+)BS\n Assessment of Nutritional Status\n Malnourished\n Patient at risk due to:\n Other: NPO, needs tube feeds if within goals of care\n Estimated Nutritional Needs\n Calories: 1125-1260kcals/ day (25-28cal/kg)\n Protein:49-63g/day (1.1-1.4 g/kg)\n Fluid: per team\n Calculations based on: admit weight\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n Remains NPO, would need nutrition support if within goals of care. \n RN, code may change to CMO.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n Tube feeding recommendations will be provided if within\n goals of care.\n Please consult if family wishes to initiate enteral feeds via NGT.\n As of now, not indicated.\n Page w/ questions #\n 12:26\n" }, { "category": "Nursing", "chartdate": "2202-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390241, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert. Opens eyes to voice. Pt moaning in bed, but not speaking.\n Does not follow commands. MAE, lifting and holding bilateral UE.\n PERLL. Denies pain.\n Action:\n Neuro checks q4h.\n Response:\n Neuro status unchanged.\n Plan:\n Neuro checks q4hours. Monitor pt\ns comfort level.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on high flow mask with 40% Fi02. LSCTA. O2 sats low 90\n Action:\n Weaned pt to 3L NC. Nebs as ordered.\n Response:\n O2 sats remained low 90\ns. Respiratory status stable.\n Plan:\n Monitor respiratory status closely.\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390423, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 1-2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n oob to chair\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, mostly moaning\n ue/le will move spontaneously right > left\n Perrla\n This afternoon patient lethargic but rouseable.\n Action:\n Monitor neuro exam\n oob to chair\n patient had pt\n Response:\n No change in neuro exam.\n Patient more alert when oob to chair, will open eyes spontaneously.\n Smiling, attempts to vocalize.\n Had small amount of diet in am, when she was more alert, refuses to\n take po in evening.\n Plan:\n Continue to monitor neuro exam\n Oob to chair as tolerated.\n Transfer to nursing unit\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient base line rhythm sinus rhythm with occasional pvc rate 60-80s\n Patient noted today to go in to sinus tachy 120-130\ns for short periods\n , bp remains stable during these episodes.\n Action:\n Micu team, reviewed patient.\n Ekg obtained reviewed.\n To continue iv lopressor dose at 5mgs Q6\n Response:\n Continues to have episodes , team aware.\n Plan:\n Patient to transfer to nursing floor.\n Will continue to monitor rhythm.\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390424, "text": "Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Improved today - but not back near baseline.\n 2) Increased Cough/O2 Requirement/CHF: CTX ( of CTX). Tapering\n steroid dose. CHF as primary driver of acute changes. Compensated for\n moment with respect to CHF but with minimal reserve.\n Will transfer back to the floor. Have discussed with the patient\n daughter, who is understanding of the patient\ns high potential to\n decompensate again. However, she would like to continue to pursue\n current management for the time being.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 1-2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n oob to chair\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, mostly moaning\n ue/le will move spontaneously right > left\n Perrla\n This afternoon patient lethargic but rouseable.\n Action:\n Monitor neuro exam\n oob to chair\n patient had pt\n Response:\n No change in neuro exam.\n Patient more alert when oob to chair, will open eyes spontaneously.\n Smiling, attempts to vocalize.\n Had small amount of diet in am, when she was more alert, refuses to\n take po in evening.\n Plan:\n Continue to monitor neuro exam\n Oob to chair as tolerated.\n Transfer to nursing unit\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient base line rhythm sinus rhythm with occasional pvc rate 60-80s\n Patient noted today to go in to sinus tachy 120-130\ns for short periods\n , bp remains stable during these episodes.\n Action:\n Micu team, reviewed patient.\n Ekg obtained reviewed.\n To continue iv lopressor dose at 5mgs Q6\n Response:\n Continues to have episodes , team aware.\n Plan:\n Patient to transfer to nursing floor.\n Will continue to monitor rhythm.\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390426, "text": "Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Improved today - but not back near baseline.\n 2) Increased Cough/O2 Requirement/CHF: CTX ( of CTX). Tapering\n steroid dose. CHF as primary driver of acute changes. Compensated for\n moment with respect to CHF but with minimal reserve.\n Will transfer back to the floor. Have discussed with the patient\n daughter, who is understanding of the patient\ns high potential to\n decompensate again. However, she would like to continue to pursue\n current management for the time being.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 1-2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n oob to chair\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, mostly moaning\n ue/le will move spontaneously right > left\n Perrla\n This afternoon patient lethargic but rouseable.\n Action:\n Monitor neuro exam\n oob to chair\n patient had pt in am\n Response:\n No change in neuro exam.\n Patient more alert when oob to chair, will open eyes spontaneously.\n Smiling, attempts to vocalize.\n Had small amount of diet in am, when she was more alert, refuses to\n take po in evening.\n Plan:\n Continue to monitor neuro exam\n Oob to chair as tolerated.\n Transfer to nursing unit\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient base line rhythm sinus rhythm with occasional pvc rate 60-80s\n Patient noted today to go in to sinus tachy 120-130\ns for short periods\n , bp remains stable during these episodes.\n Action:\n Micu team, reviewed patient.\n Ekg obtained reviewed.\n To continue iv lopressor dose at 5mgs Q6\n Response:\n Continues to have episodes , team aware.\n Plan:\n Patient to transfer to nursing floor.\n Will continue to monitor rhythm.\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390427, "text": "Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Improved today - but not back near baseline.\n 2) Increased Cough/O2 Requirement/CHF: CTX ( of CTX). Tapering\n steroid dose. CHF as primary driver of acute changes. Compensated for\n moment with respect to CHF but with minimal reserve.\n Will transfer back to the floor. Have discussed with the patient\n daughter, who is understanding of the patient\ns high potential to\n decompensate again. However, she would like to continue to pursue\n current management for the time being.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 1-2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n oob to chair\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, mostly moaning\n ue/le will move spontaneously right > left\n Perrla\n This afternoon patient lethargic but rouseable.\n Action:\n Monitor neuro exam\n oob to chair\n patient had pt in am\n Response:\n No change in neuro exam.\n Patient more alert when oob to chair, will open eyes spontaneously.\n Smiling, attempts to vocalize.\n Had small amount of diet in am, when she was more alert, refuses to\n take po in evening.\n Plan:\n Continue to monitor neuro exam\n Oob to chair as tolerated.\n Transfer to nursing unit\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient base line rhythm sinus rhythm with occasional pvc rate 60-80s\n Patient noted today to go in to sinus tachy 120-130\ns for short periods\n , bp remains stable during these episodes.\n Action:\n Micu team, reviewed patient.\n Ekg obtained reviewed.\n To continue iv lopressor dose at 5mgs Q6\n Response:\n Continues to have episodes , team aware.\n Plan:\n Patient to transfer to nursing floor.\n Will continue to monitor rhythm.\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNI (do not intubate)\n Height:\n 60 Inch\n Admission weight:\n 44.7 kg\n Daily weight:\n 46.5 kg\n Allergies/Reactions:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Precautions:\n PMH: COPD, Diabetes - Insulin, ETOH\n CV-PMH: Hypertension\n Additional history: Previous Right MCA stroke (no residual defecit),\n Osteoperosis, Depression.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:40\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 68 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 603 mL\n 24h total out:\n 470 mL\n Pertinent Lab Results:\n Sodium:\n 149 mEq/L\n 01:57 AM\n Potassium:\n 4.6 mEq/L\n 01:57 AM\n Chloride:\n 109 mEq/L\n 01:57 AM\n CO2:\n 33 mEq/L\n 01:57 AM\n BUN:\n 40 mg/dL\n 01:57 AM\n Creatinine:\n 0.8 mg/dL\n 01:57 AM\n Glucose:\n 134 mg/dL\n 01:57 AM\n Hematocrit:\n 32.6 %\n 01:57 AM\n Finger Stick Glucose:\n 235\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:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390428, "text": "Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Improved today - but not back near baseline.\n 2) Increased Cough/O2 Requirement/CHF: CTX ( of CTX). Tapering\n steroid dose. CHF as primary driver of acute changes. Compensated for\n moment with respect to CHF but with minimal reserve.\n Will transfer back to the floor. Have discussed with the patient\n daughter, who is understanding of the patient\ns high potential to\n decompensate again. However, she would like to continue to pursue\n current management for the time being.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 1-2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n oob to chair\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, mostly moaning\n ue/le will move spontaneously right > left\n Perrla\n This afternoon patient lethargic but rouseable.\n Action:\n Monitor neuro exam\n oob to chair\n patient had pt in am\n Response:\n No change in neuro exam.\n Patient more alert when oob to chair, will open eyes spontaneously.\n Smiling, attempts to vocalize.\n Had small amount of diet in am, when she was more alert, refuses to\n take po in evening.\n Plan:\n Continue to monitor neuro exam\n Oob to chair as tolerated.\n Transfer to nursing unit\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient base line rhythm sinus rhythm with occasional pvc rate 60-80s\n Patient noted today to go in to sinus tachy 120-130\ns for short periods\n , bp remains stable during these episodes.\n Action:\n Micu team, reviewed patient.\n Ekg obtained reviewed.\n To continue iv lopressor dose at 5mgs Q6\n Response:\n Continues to have episodes , team aware.\n Plan:\n Patient to transfer to nursing floor.\n Will continue to monitor rhythm.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 15:59 ------\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 389793, "text": "81 yo woman with prior CVA, COPD, severe AS and h/o adeno carcinoma adm\n with 2d h/o altered MS finally with obtundation and an increased O2\n requirement. Brought to Ed where altered MS. by Neuro to r/o\n stroke, CXR read as possible PNA adm to ICU. Here 97.5/ 86/ 126/66.\n Pursed lip breathing. Arouses to voice.\n Altered mental status (not Delirium)\n Assessment:\n Patient is drowsy, waking up to call, not following any commands,\n garbled speech, not responding to verbal commands.Oriented to self,\n Not opening eyes, moving rt side purposefully, lt hand flaccid, lt\n leg with draws to pain, PERL.\n Action:\n Neuro checks q4h, Reoriented to place and person, SBP wnl. MRI done\n Response:\n Unchanged neuro status, Pending MRI report\n Plan:\n Cont to monitor.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, LS clear, non productive cough. O 2sat 94-98%\n Action:\n O2 down to 4L from 6L by NC, turned q2h, >30*, IVF 1L given, K+\n 40mmol replaced.\n Response:\n For CXR this morning, remains afebrile, O2 sat remains stable\n Plan:\n Pulm hygiene, chest PT, >30*, cont with anbx.\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient ruling out for NSTEMI, cardiac enzymes wnl. Troponin 0.5 with\n labs at ,\n Action:\n 5 beat run of V tach noted, EKG done, seen by MICU MD, unchanged form\n previous one, K+ replaced.\n Response:\n Irregular HR with pvc\ns / pac\ns, team aware.\n Plan:\n Cont to monitor, repeat enzymes, support to patient and family.\n" }, { "category": "Nutrition", "chartdate": "2202-09-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 390231, "text": "Subjective\n Patient w/ AMS\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 44.7 kg\n 46.7 kg ( 12:00 AM)\n Fluid shifts\n 19.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 98%\n Not applicable\n Not available\n Diagnosis: PNA\n PMHx:\n Food allergies and intolerances: None per POE\n Pertinent medications: HISS, omeprazole, MVI, Ceftriaxone, asa,\n azithromycin, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 05:09 AM\n Glucose Finger Stick\n 177\n 10:00 AM\n BUN\n 45 mg/dL\n 05:09 AM\n Creatinine\n 1.0 mg/dL\n 05:09 AM\n Sodium\n 143 mEq/L\n 05:09 AM\n Potassium\n 5.5 mEq/L\n 05:09 AM\n Chloride\n 105 mEq/L\n 05:09 AM\n TCO2\n 29 mEq/L\n 05:09 AM\n PO2 (arterial)\n 103 mm Hg\n 03:32 PM\n PCO2 (arterial)\n 36 mm Hg\n 03:32 PM\n pH (arterial)\n 7.52 units\n 03:32 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:32 PM\n Calcium non-ionized\n 9.0 mg/dL\n 03:07 AM\n Phosphorus\n 2.6 mg/dL\n 03:07 AM\n Magnesium\n 2.0 mg/dL\n 03:07 AM\n ALT\n 18 IU/L\n 03:31 AM\n Alkaline Phosphate\n 127 IU/L\n 03:31 AM\n AST\n 42 IU/L\n 03:31 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:31 AM\n WBC\n 17.9 K/uL\n 05:09 AM\n Hgb\n 9.8 g/dL\n 05:09 AM\n Hematocrit\n 32.7 %\n 05:09 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/ (+)BS\n Assessment of Nutritional Status\n Malnourished\n Patient at risk due to:\n Other:\n Estimated Nutritional Needs\n Calories: (25-28cal/kg)\n Protein: (1.1-1.4 g/kg)\n Fluid: per team\n Calculations based on:\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n Tube feeding recommendations:\n" }, { "category": "Nursing", "chartdate": "2202-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390005, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs diminished\n Patient on open face mask 40%, o2 sats 88-92%\n Weak cough\n Action:\n Pulmonary toileting and chest pt preformed\n Drs aware of o2 sats 88-92%\n Iv antibiotics and steroids given as ordered\n Response:\n Maintaining o2 sats >90%\n Plan:\n Continue with pulmonary toileting and chest pt\n Wean o2 as tolerated, but no greater than 40% o2\n Continue iv antibiotics and steroids\n Altered mental status (not Delirium)\n Assessment:\n Patient very lethargic at beginning of shift\n Does not follow commands\n Minimal verbal, no speech\n Left ue/le withdraws, right ue/le will move spontaneously\n Perrla\n Action:\n Monitor neuro exam\n Hold narcotics\n Response:\n No change in neuro exam.\n Plan:\n Continue to monitor\n Urine output remains low 10-25cc hrly, micu team made aware.\n" }, { "category": "Physician ", "chartdate": "2202-09-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390421, "text": "Chief Complaint: CHF, Respiratory Failure, CVA\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 More alert this AM\n 24 Hour Events:\n On 2L NC overnight\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:07 AM\n Other medications:\n per ICU resident\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Respiratory: No(t) Tachypnea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.6\nC (96\n HR: 74 (61 - 76) bpm\n BP: 107/54(67) {107/53(67) - 139/67(82)} mmHg\n RR: 12 (11 - 16) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.5 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 519 mL\n 356 mL\n PO:\n TF:\n IVF:\n 519 mL\n 356 mL\n Blood products:\n Total out:\n 920 mL\n 295 mL\n Urine:\n 920 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -401 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, mental status\n improved today\n Labs / Radiology\n 10.0 g/dL\n 318 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.6 mEq/L\n 40 mg/dL\n 109 mEq/L\n 149 mEq/L\n 32.6 %\n 13.7 K/uL\n [image002.jpg]\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n 01:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n 13.7\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n 32.6\n Plt\n 333\n 364\n 373\n 320\n 318\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n 0.8\n TropT\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n 134\n Other labs: PT / PTT / INR:14.5/37.2/1.3, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Improved today - but not back near baseline.\n 2) Increased Cough/O2 Requirement/CHF: CTX ( of CTX). Tapering\n steroid dose. CHF as primary driver of acute changes. Compensated for\n moment with respect to CHF but with minimal reserve.\n Will transfer back to the floor. Have discussed with the patient\n daughter, who is understanding of the patient\ns high potential to\n decompensate again. However, she would like to continue to pursue\n current management for the time being.\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI (do not intubate)\n" }, { "category": "Nursing", "chartdate": "2202-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390422, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 1-2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n oob to chair\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2202-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390101, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs diminished\n o2 sats 88-99%, on 3l NC\n Weak cough\n Action:\n Pulmonary toileting and chest pt preformed\n Drs aware of o2 sats 88-92%\n Iv antibiotics and steroids given as ordered\n Response:\n Maintaining o2 sats >93\n Plan:\n Continue with pulmonary toileting and chest pt\n Wean o2 as tolerated, but no greater than 40% or 3l nc\n Continue iv antibiotics and steroids\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, no speech\n ue/le will move spontaneously right > left\n Perrla\n Action:\n Monitor neuro exam\n Response:\n No change in neuro exam.\n Plan:\n Continue to monitor\n" }, { "category": "Physician ", "chartdate": "2202-09-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390219, "text": "Chief Complaint:\n 24 Hour Events:\n -Around 2 PM acutely desatted into the mid 80s. Was changed over to\n shovel mask with persistent desaturations. Crackles at bases\n bilaterally. Moaning but could not endorse chest pain. Morphine 2 mg\n given, EKG obtained which showed new T wave inversions. Troponins\n cycled, first set elevated at 0.83 (was .75 at time of stroke). Second\n set stable at 0.85. Cardiology notified; feel this is likely demand\n ischemia. On lovenox anyway right now given stroke. Serial EKGs\n and following enzymes. Saturations improved on nonrebreather; gas\n shows O2 of 102 on NRB - weaning down to shovel mask.\n -azithromycin should be continued for day course so didn't\n discontinue (on day 5)\n -switched to PO steroids 60 mg daily for ? COPD exacerbation\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:20 PM\n Metoprolol - 06:10 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 81 (70 - 85) bpm\n BP: 116/67(78) {98/47(59) - 140/79(87)} mmHg\n RR: 13 (10 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.7 kg (admission): 44.7 kg\n Total In:\n 371 mL\n 50 mL\n PO:\n TF:\n IVF:\n 371 mL\n 50 mL\n Blood products:\n Total out:\n 334 mL\n 128 mL\n Urine:\n 334 mL\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 37 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: 7.52/36/103//6\n PaO2 / FiO2: 258\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 373 K/uL\n 9.8 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 35 mg/dL\n 104 mEq/L\n 143 mEq/L\n 32.7 %\n 17.9 K/uL\n [image002.jpg]\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n WBC\n 12.2\n 14.3\n 15.8\n 17.9\n Hct\n 30.6\n 30.1\n 32.3\n 32.7\n Plt\n 259\n 333\n 364\n 373\n Cr\n 0.7\n 0.8\n 0.9\n TropT\n 0.50\n 0.55\n 0.75\n 0.72\n 0.83\n 0.85\n TCO2\n 30\n Glucose\n 103\n 134\n 119\n Other labs: PT / PTT / INR:18.3/33.9/1.7, CK / CKMB /\n Troponin-T:193/4/0.85, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Hypoxia - Unclear why desaturated but could have developed some\n acute pulmonary edema secondary to her stenotic aortic valve in setting\n of mild hypertension/tachycardia. Responded to morphine,\n respositioning, and changing to high flow mask. CXR doesn't show any\n clear evidence for congestion, no significant infiltrates suggestive of\n a new, acute parencyhmal process. An acute coronary event unlikely to\n have caused desat: although transient new T wave inversions seen on EKG\n as well as mild troponin elevation above baseline, likely secondary to\n demand ischemia in setting of her hypoxia and increased work of\n breathing rather than being the causative .\n -Continue to wean from high flow mask as tolerated, maintaining O2 sats\n of 92 - 94%\n -continue treatment of possible underlying PNA with ceftriaxone and\n azithromycin to complete 7 day course (now on day 6)\n -day 2 of PO prednisone at 60 mg - continue for 2 more days then taper\n to 20 mg\n -nebs PRN\n -cycling enzymes: troponins steady at 0.83, .85. Total CKs increased\n but CK-mB fractions not significant. New T wave inversions in V1-V4\n but likely nonspecific and in setting of demand ischemia. Cardiology\n aware; already on lovenox for recent ischemic stroke; doesn't\n require any other anticoagulation or change in management.\n .\n 2) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission.\n - continue to provide supportive measures s/p stroke (maintaining BPs)\n - treat pneumonia as above\n .\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS//HTN: Since last\n ECHO pt has deterioriating cardiac status with increased Aortic\n insufficiency and RV hypokinesis. Probably affecting respiratory\n status secondary to tenous aortic valve however no overt evidence of\n pulmonary edema.\n -holding lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - lopressor 5mg IV q6h\n .\n 4) Recent CVA - Secondary to ischemic stroke, bilateral, affecting PCA,\n MCA, ACA. Neurology feels current deficits are secondary to\n recrudescence of prior stroke. Does continue to have some mental\n status changes likely from encephalopathy from recent stroke. Unclear\n whether embolic or thrombotic but embolic seems more likely given wide\n distribution affected. Echo does not show any clot.\n -Obtain carotid duplex\n -Continue lovenox 40 mg \n -continue aspirin 81 mg daily\n -Touch base with Neuro re: outpatient MRI; long-term anticoagulation.\n .\n 5 Leukocytosis: Has slowly drifted up over last several days. Neg\n Urine cx, blood cxs, CXR. CTX/azithro to complete Community Aquired\n PNA course. Has not been febrile. Likely secondary to prednisone\n course.\n .\n 6) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 7) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - f/u iron studies, b12, folate\n .\n 8)FEN: replete lytes, NPO\n .\n 9)Propohylaxis: pneumoboots, lovenox\n .\n 10)code: DNR/DNI\n .\n 11) Dispo - to floor pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390226, "text": "Chief Complaint: Hypoxemic Respiratory failure, CHF, CVAs\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 Had been on high flow mask overnight but now on nasal cannula\n 24 Hour Events:\n EKG - At 02:06 PM\n EKG - At 07:06 PM\n Had increase O2 requirement yesterday with new precordial lateral TWI\n on EKG\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:20 PM\n Metoprolol - 06:10 AM\n Enoxaparin (Lovenox) - 08:00 AM\n Other medications:\n per ICU resident\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Respiratory: No(t) Tachypnea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.8\nC (96.5\n HR: 81 (70 - 85) bpm\n BP: 116/92(97) {98/47(59) - 140/92(97)} mmHg\n RR: 15 (10 - 19) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.7 kg (admission): 44.7 kg\n Total In:\n 411 mL\n 167 mL\n PO:\n TF:\n IVF:\n 411 mL\n 167 mL\n Blood products:\n Total out:\n 334 mL\n 240 mL\n Urine:\n 334 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 77 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.52/36/103/29/6\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: No acute distress, moaning\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 373 K/uL\n 116 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 45 mg/dL\n 105 mEq/L\n 143 mEq/L\n 32.7 %\n 17.9 K/uL\n [image002.jpg]\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n WBC\n 12.2\n 14.3\n 15.8\n 17.9\n Hct\n 30.6\n 30.1\n 32.3\n 32.7\n Plt\n 259\n 333\n 364\n 373\n Cr\n 0.7\n 0.8\n 0.9\n 1.0\n TropT\n 0.50\n 0.55\n 0.75\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 103\n 134\n 119\n 116\n Other labs: PT / PTT / INR:18.3/33.9/1.7, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Continues to wax and wane - worse today\n probably in setting of hypoxemia with her recent embolic CVAs.Cont \n Lovenox. Carotid U/S\n 2) Increased Cough/O2 Requirement: Treating for CAP with azithro and\n CTX ( of CTX). Tapering steroid dose. CHF management difficult as\n below.\n 3) CHF:Managment difficult given AS and diastolic dysfunction. No\n further diuresis for the moment\n 4) Decreased urine output: Cr also going up. Will not give any fluid\n given CHF and hope she auto-regulates\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2202-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390188, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes to voice, not following commands, MAE,\n able to lift UE, PERL, moaning most of the time, but denies pain.\n Action:\n Neuro checks q4h, position changed q2h,\n Response:\n Slept for short intervals, unchanged neuro status, sound is garbled,\n not talking ,\n Plan:\n Cont to monitor, Neuro checks Q4H, Assess pain and treat, support to\n pt and family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was on a 100% non rebreather earlier, LS clear, O 2sat 90-94%\n Action:\n Changed to hi flow mask with 60% Fio2, and weaned down Fio2 to 40%,\n serial cardiac enzymes x2 sent.\n Response:\n O 2sat remains 90-93% with 40% Fio2, Enzymes trending down.\n Plan:\n Pulm hygiene, wean Fio2 as tolerates.\n" }, { "category": "Physician ", "chartdate": "2202-09-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390302, "text": "Chief Complaint: Respiratory Failure, CHF, CVA\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 Still moaning consistently, but slightly more interactive\n 24 Hour Events:\n Satting in high 90s on 2L nasal cannula\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:08 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: Minimal\n Flowsheet Data as of 11:36 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: 77 (67 - 77) bpm\n BP: 123/64(79) {112/49(65) - 138/75(90)} mmHg\n RR: 15 (11 - 16) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.2 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 540 mL\n 165 mL\n PO:\n TF:\n IVF:\n 540 mL\n 165 mL\n Blood products:\n Total out:\n 517 mL\n 490 mL\n Urine:\n 517 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23 mL\n -325 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, moaning\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), exam difficult due to\n moaning\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), exam difficult due to moaning\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, less asymmetric (previously L > R)\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 320 K/uL\n 123 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 47 mg/dL\n 108 mEq/L\n 146 mEq/L\n 32.4 %\n 16.6 K/uL\n [image002.jpg]\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n Plt\n 333\n 364\n 373\n 320\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n TropT\n 0.75\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n Other labs: PT / PTT / INR:16.1/40.5/1.4, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Comments: unable to take pos at the moment\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2202-09-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390303, "text": "Chief Complaint: Respiratory Failure, CHF, CVA\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 Still moaning consistently, but slightly more interactive\n 24 Hour Events:\n Satting in high 90s on 2L nasal cannula\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:08 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: Minimal\n Flowsheet Data as of 11:36 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: 77 (67 - 77) bpm\n BP: 123/64(79) {112/49(65) - 138/75(90)} mmHg\n RR: 15 (11 - 16) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.2 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 540 mL\n 165 mL\n PO:\n TF:\n IVF:\n 540 mL\n 165 mL\n Blood products:\n Total out:\n 517 mL\n 490 mL\n Urine:\n 517 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23 mL\n -325 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, moaning\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), exam difficult due to\n moaning\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), exam difficult due to moaning\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, less asymmetric (previously L > R)\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 320 K/uL\n 123 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 47 mg/dL\n 108 mEq/L\n 146 mEq/L\n 32.4 %\n 16.6 K/uL\n [image002.jpg]\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n Plt\n 333\n 364\n 373\n 320\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n TropT\n 0.75\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n Other labs: PT / PTT / INR:16.1/40.5/1.4, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Continues to wax and wane\n better today but\n still no where near baseline. Cont Lovenox for CVAs\n 2) Increased Cough/O2 Requirement: Completed azithro course. CTX (\n of CTX). Tapering steroid dose. CHF as primary driver of acute\n changes\n 3) CHF:Managment difficult given AS and diastolic dysfunction. No\n further diuresis for the moment\n 4) Decreased urine output: Cr down today. Urine output stable.\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Comments: unable to take pos at the moment\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2202-09-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390192, "text": "Chief Complaint:\n 24 Hour Events:\n -Around 2 PM acutely desatted into the mid 80s. Was changed over to\n shovel mask with persistent desaturations. Crackles at bases\n bilaterally. Moaning but could not endorse chest pain. Morphine 2 mg\n given, EKG obtained which showed new T wave inversions. Troponins\n cycled, first set elevated at 0.83 (was .75 at time of stroke). Second\n set stable at 0.85. Cardiology notified; feel this is likely demand\n ischemia. On lovenox anyway right now given stroke. Serial EKGs\n and following enzymes. Saturations improved on nonrebreather; gas\n shows O2 of 102 on NRB - weaning down to shovel mask.\n -azithromycin should be continued for day course so didn't\n discontinue (on day 5)\n -switched to PO steroids 60 mg daily for ? COPD exacerbation\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:20 PM\n Metoprolol - 06:10 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 81 (70 - 85) bpm\n BP: 116/67(78) {98/47(59) - 140/79(87)} mmHg\n RR: 13 (10 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.7 kg (admission): 44.7 kg\n Total In:\n 371 mL\n 50 mL\n PO:\n TF:\n IVF:\n 371 mL\n 50 mL\n Blood products:\n Total out:\n 334 mL\n 128 mL\n Urine:\n 334 mL\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 37 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: 7.52/36/103//6\n PaO2 / FiO2: 258\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 373 K/uL\n 9.8 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.1 mEq/L\n 35 mg/dL\n 104 mEq/L\n 143 mEq/L\n 32.7 %\n 17.9 K/uL\n [image002.jpg]\n 03:28 AM\n 04:30 AM\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n WBC\n 12.2\n 14.3\n 15.8\n 17.9\n Hct\n 30.6\n 30.1\n 32.3\n 32.7\n Plt\n 259\n 333\n 364\n 373\n Cr\n 0.7\n 0.8\n 0.9\n TropT\n 0.50\n 0.55\n 0.75\n 0.72\n 0.83\n 0.85\n TCO2\n 30\n Glucose\n 103\n 134\n 119\n Other labs: PT / PTT / INR:18.3/33.9/1.7, CK / CKMB /\n Troponin-T:193/4/0.85, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assessment and Plan\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Hypoxia - Unclear why desaturated but could have developed some\n acute pulmonary edema secondary to her stenotic aortic valve in setting\n of mild hypertension/tachycardia. Responded to morphine,\n respositioning, and changing to high flow mask. CXR doesn't show any\n clear evidence for congestion, no significant infiltrates suggestive of\n a new, acute parencyhmal process. An acute coronary event unlikely to\n have caused desat: although transient new T wave inversions seen on EKG\n as well as mild troponin elevation above baseline, likely secondary to\n demand ischemia in setting of her hypoxia and increased work of\n breathing rather than being the causative .\n -Continue to wean from high flow mask as tolerated, maintaining O2 sats\n of 92 - 94%\n -continue treatment of possible underlying PNA with ceftriaxone and\n azithromycin to complete 7 day course (now on day 6)\n -day 2 of PO prednisone at 60 mg - continue for 2 more days then taper\n to 20 mg\n -nebs PRN\n -cycling enzymes: troponins steady at 0.83, .85. Total CKs increased\n but CK-mB fractions not significant. New T wave inversions in V1-V4\n but likely nonspecific and in setting of demand ischemia. Cardiology\n aware; already on lovenox for recent ischemic stroke; doesn't\n require any other anticoagulation or change in management.\n .\n 2) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission.\n - continue to provide supportive measures s/p stroke (maintaining BPs)\n - treat pneumonia as above\n .\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS//HTN: Since last\n ECHO pt has deterioriating cardiac status with increased Aortic\n insufficiency and RV hypokinesis. Probably affecting respiratory\n status secondary to tenous aortic valve however no overt evidence of\n pulmonary edema.\n -holding lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - lopressor 5mg IV q6h\n .\n 4) Recent CVA - Secondary to ischemic stroke, bilateral, affecting PCA,\n MCA, ACA. Neurology feels current deficits are secondary to\n recrudescence of prior stroke. Does continue to have some mental\n status changes likely from encephalopathy from recent stroke. Unclear\n whether embolic or thrombotic but embolic seems more likely given wide\n distribution affected. Echo does not show any clot.\n -Obtain carotid duplex\n -Continue lovenox 40 mg \n -continue aspirin 81 mg daily\n -Touch base with Neuro re: outpatient MRI; long-term anticoagulation.\n .\n 5 Leukocytosis: Has slowly drifted up over last several days. Neg\n Urine cx, blood cxs, CXR. CTX/azithro to complete Community Aquired\n PNA course. Has not been febrile. Likely secondary to prednisone\n course.\n .\n 6) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 7) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - f/u iron studies, b12, folate\n .\n 8)FEN: replete lytes, NPO\n .\n 9)Propohylaxis: pneumoboots, lovenox\n .\n 10)code: DNR/DNI\n .\n 11) Dispo - to floor pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2202-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390318, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n lungs diminished but clear\n o2 sats >96% on 2l nc\n Action:\n pulmonary toileting and chest pt preformed\n nebs given as ordered\n weaned o2 to 1L nc\n Response:\n continues to sat >96%\n Weak cough.\n no resp distress noted\n Plan:\n Continue to wean off o2 as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Does not follow commands\n Minimal verbal, mostly moaning\n ue/le will move spontaneously right > left\n Perrla\n Action:\n Monitor neuro exam\n oob to chair\n Response:\n No change in neuro exam.\n Patient more alert when oob to chair, will open eyes spontaneously.\n Smiling, attempts to vocalize.\n Plan:\n Continue to monitor neuro exam\n Oob to chair as tolerated.\n IV fluids ns started at 30cc, will continue to monitor resp status\n closely as patient at risk of pulmonary edema\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 389772, "text": "81 yo woman with prior CVA, COPD, severe AS and h/o adeno carcinoma adm\n with 2d h/o altered MS finally with obtundation and an increased O2\n requirement. Brought to Ed where altered MS. by Neuro to r/o\n stroke, CXR read as possible PNA adm to ICU. Here 97.5/ 86/ 126/66.\n Pursed lip breathing. Arouses to voice.\n Altered mental status (not Delirium)\n Assessment:\n Patient is drowsy, waking up to call, not following any commands,\n garbled speech, not responding to verbal commands.Oriented to self,\n Not opening eyes, moving rt side purposefully, lt hand flaccid, lt\n leg with draws to pain, PERL.\n Action:\n Neuro checks q4h, Reoriented to place and person, SBP wnl.\n Response:\n Unchanged neuro status, waiting for MRI.\n Plan:\n Cont to monitor, MRI today.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, LS clear, non productive cough. O 2sat 94-98%\n Action:\n O2 down to 4L from 6L by NC, turned q2h, >30*, IVF 1L given, K+\n 40mmol replaced.\n Response:\n For CXR this morning, remains afebrile, O2 sat remains stable\n Plan:\n Pulm hygiene, chest PT, >30*, cont with anbx.\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient ruling out for NSTEMI, cardiac enzymes wnl. Troponin 0.5 with\n labs at ,\n Action:\n 5 beat run of V tach noted, EKG done, seen by MICU MD, unchanged form\n previous one, K+ replaced.\n Response:\n Irregular HR with pvc\ns / pac\ns, team aware.\n Plan:\n Cont to monitor, repeat enzymes, support to patient and family.\n" }, { "category": "Physician ", "chartdate": "2202-09-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 389987, "text": "Chief Complaint: hypoxia\n HPI:\n This is an 81 year old female with h/o right sided MCA stroke with\n residual left hemiparesis, COPD, Atrial flutter, and partial\n gastrectomy for gastric cancer who initially presented with altered\n mental status and worsening left sided weakness. She was also noted to\n have worsening shortness of breath. She presented to the ED where she\n was found to be dyspneic, hypoxic, with a UTI, and suspected of having\n pneumonia. She also had a troponin of .57 and was therefore admitted\n to the MICU. She wa salso given levaquin. She was ruled out for a\n myocardial infarction in the MICU. Given her altered mental\n status and worsening left sided weakness, it was unclear whether\n she was just exhibiting recrudescence of her old stroke, vs. a\n new ischemic event. She underwent an MRI which showed multiple\n new small embolic strokes. As her multiple other medical\n problems were more stable at this point, the decision was made to start\n her on levenox for her embolic strokes and transfer her to the\n Neurology Stroke servic and transferred to the Neurology service on\n .\n The neurology team considered her new symptoms to be a recrudescence\n of her old stroke in the context of her UTI. Similarly, they felt her\n altered mental status could not be explained by the location or size of\n the new infarcts. She underwent an EEG which showed widespread\n encephalopathy, likely toxic metabolic. She also underwent a TTE which\n showed significantly worsening aortic regurgitation and a dilated and\n hypokinetic right ventricle, which are new findings compared with her\n most recent echo in .\n On the patient was found to be repeatedly hypoxic on the neurology\n floor. She wa on a face mask with 40% oxygen, but repeatedly removed\n the mask during which she desaturated to 85%. Her oxygen levels\n increased when her facemask was replaced. She was also found to be\n wheezy on exam. EKG showed psuedonormalization of T waves in V2 and\n V3. She was given albuterol nebulizers with improvement in her\n oxygenation. An ABG was performed which showed a lactate of 8.8. She\n was transferred to the MICU for treatment of hypoxia and elevated\n lactate.\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 01:04 PM\n Azithromycin - 02:04 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:30 PM\n Metoprolol - 06:32 PM\n Other medications:\n HISS\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Aspirin 81 mg PO DAILY\n Multivitamin daily\n Azithromycin 500 mg IV Q24H day 1 = \n Omeprazole 20 mg PO DAILY\n CeftriaXONE 1 gm IV Q24H Day 1= \n Fluoxetine 20 mg PO DAILY\n Lovenox 40 mg sc BID\n OUTPATIENT MEDICATIONS: (per records)\n ALBUTEROL 2 puffs po three times a day PRN\n BUPROPION HCL 100 mg PO daily\n FLUOXETINE 40 mg PO daily\n HYDROCHLOROTHIAZIDE 25 mg PO daily\n IPRATROPIUM BROMIDE MDI 4 */daily\n LISINOPRIL 5 mg daily\n OMEPRAZOLE 20 mg PO daily\n OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 4*/day PRN\n ACETAMINOPHEN 325-650 mg TID PRN\n DOCUSATE SODIUM 100 mg PO BID\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n -atrial flutter\n -History of right sided MCA ischemic stroke (residual mild left\n hemiparesis)\n -Severe aortic stenosis: TTE showed severe AS and diastolic\n heart failure.\n -Gastric adenocarcinoma s/p partial gastrectomy in \n -Hypertension.\n -Hyperlipidemia.\n -COPD (on 2L supplementary O2 by nasal cannula PRN)\n -Borderline glucose intolerance\n -Osteoporosis.\n -Depression.\n -History of alcohol abuse\n -History of pyloric stenosis.\n .\n .\n Family History: Parents died in their 70s of unknown causes.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Social History: She smoked 1ppd for 50 years. Has a history of\n alcohol abuse but none in five years per previous notes. Lives with\n her daughter and ambulates with a cane since her stroke\n Review of systems:\n Flowsheet Data as of 06:41 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.8\nC (98.2\n HR: 94 (78 - 108) bpm\n BP: 104/62(72) {104/53(63) - 127/67(82)} mmHg\n RR: 19 (16 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.8 kg (admission): 44.7 kg\n Total In:\n 1,372 mL\n 277 mL\n PO:\n TF:\n IVF:\n 1,372 mL\n 27 mL\n Blood products:\n Total out:\n 338 mL\n 28 mL\n Urine:\n 338 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,034 mL\n 249 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 94%\n Physical Examination\n PHYSICAL EXAM: 98.2 104/62 93 95% 40% facemask\n GEN: severely cachectic, somnulent, rouses to touch/loud voice with\n moans\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. Neck Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Faint mumur at\n apex. JVP= 7 cm.\n LUNGS: CTAB w/ dry crackles at bases, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Unable to answer questions reliably. Will intermittently say\n Yes, No, Okay. Intermittently able to follow simple commands (like move\n your right leg). L HF . L biceps 2+ reflex. R biceps 3+. L hand\n flacid. L leg below knee flacid w/ foot drop and upgoing toes. R leg\n hypertonic, with downgoing toes. No clonus on either side\n .\n Studies:\n EEG : Abnormal portable EEG due primarily to the disorganization\n and slowing of the background. This indicates a widespread\n encephalopathy. Metabolic disturbances, infection, and medications are\n among the most common causes. There were no prominent focal\n abnormalities, but encephalopathies may obscure focal findings. There\n were frequent sharp waves, usually symmetric, indicating areas of\n cortical hypersynchrony. This does not necessarily indicate the\n presence of seizures at other times.\n .\n ECHO - Overall left ventricular systolic function is low normal\n (LVEF 50%). There is no ventricular septal defect. The right\n ventricular free wall is hypertrophied. The right ventricular cavity is\n dilated with severe global free wall hypokinesis. The aortic valve\n leaflets are moderately thickened. There is severe aortic valve\n stenosis. Moderate (2+) aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen (which may be underestimated). The left\n ventricular inflow pattern suggests impaired relaxation.\n .\n CXR : There is a small right pleural effusion with adjacent\n atelectasis is very similar. Allowing for rotation, the appearance of\n the lung parenchyma is unchanged, with degree of emphysema. The cardiac\n silhouette is borderline in size. There is no pulmonary edema or\n pneumothorax.\n .\n MRI Head/Brain/Neck :\n 1. Multiple small acute infarcts, diffusely scattered in the cerebral\n and cerebellar hemispheres, on both sides, in the ACA, MCA and the PCA\n territories, likely related to an embolic source. To correlate\n clinically.\n 2. Patent major intracranial arteries without focal flow-limiting\n stenosis, occlusion or aneurysm more than 3 mm within the resolution of\n MR angiogram with bilateral fetal PCA variant and hypoplastic A1\n segment of the right anterior cerebral artery.\n 3. Suboptimal quality of the contrast-enhanced MR angiogram of the\n neck, which makes assessment inaccurate.\n .\n ekg: sinus tachycardia at rate of 117, normal axis, normal intervals,\n pseudonormalization of t waves in V2 and V3.\n Labs / Radiology\n 259 K/uL\n 9.3 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 23 mg/dL\n 35 mEq/L\n 100 mEq/L\n 3.5 mEq/L\n 139 mEq/L\n 30.6 %\n 12.2 K/uL\n [image002.jpg]\n \n 2:33 A10/7/ 07:20 PM\n \n 10:20 P10/8/ 03:28 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.6\n 12.2\n Hct\n 28.3\n 30.6\n Plt\n 247\n 259\n Cr\n 0.8\n 0.7\n TropT\n 0.50\n 0.50\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:15.8/36.2/1.4, CK / CKMB /\n Troponin-T:91//0.50, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assessment and Plan:\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n .\n 1) Altered Mental Status: Likely encephalopathy in setting of recent\n stroke, may also have a contribution from infection. Improved from\n admission. Flat CKs suggest troponin elevation either from stroke or\n more remote cardiac event.\n - continue to provide supportive measures s/p stroke\n - treat pneumonia as below\n 2) Increased Cough/O2 Requirement: Probable pneumonia\n (community-aquired), vs COPD flare.\n -CTX/Azithromycin to complete 7 day course\n -Continue ipratroprium and albuterol\n -methylprednisolone\n -Titrate oxygen to comfort and O2 sat between 92-94%\n 3) Cardiac: Chronic Diastolic Heart Failure/Severe AS/Elevated\n Troponin/Aflutter/HTN: Since last ECHO pt has deterioriating cardiac\n status with increased Aortic insufficiency and RV hypokinesis. ekg may\n have worrisome signs with pseudonormalization of T waves. Flat CKs\n suggest troponin elevation may be from remote cardiac event. ECHO\n suggest completed infarct. Concerned that pt stroke was from a\n showering of cardiac emboli.\n - hold lisinopril to let BP autoregulate (goal SBP 100-140) given may\n not tolerate higher pressure with her severe AS w/ AR.\n - anticoagulation per neurology given recent mult embolic strokes\n - cont aspirin 81 mg daily\n - lopressor 5mg 5mg IV q6h\n - trend enzymes\n .\n 4)elevated lactate: potentially be from increased work of\n breathing. Is normotensive making septic shock unlikely.\n -continue antibiotics\n -oxygen supplementation\n .\n 5)multiple cerebral infarcts: lovenox 40mg . sourc of emboli has\n not been found.\n 4) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke.\n -HISS w/ treatment for FSG >200.\n 5) Anemia: microcytic with high RDW suggests mixed population. Given\n partial gastrectomy may have B12 deficiency which can affect mental\n status.\n - please check iron studies, B12, folate as pt may need all of these\n repleted. If B12 is low pls give IM injection.\n 6) Leukocytosis: neg Urine cx, benign abd exam, on CTX/azithro to\n complete Community Aquired PNA course. also be reactive in setting\n of multiple acute strokes.\n - trend and culture pt (sputum, CXR, UA, stool for c. diff) if spikes\n temp <95 for > 100.5\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:04 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2202-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390183, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient is alert, opening eyes to voice, not following commands, MAE,\n able to lift UE, PERL, moaning most of the time, but denies pain.\n Action:\n Neuro checks q4h, position changed q2h,\n Response:\n Slept for short intervals, unchanged neuro status, sound is garbled,\n not talking ,\n Plan:\n Cont to monitor, Neuro checks Q4H, Assess pain and treat, support to\n pt and family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was on a 100% non rebreather earlier, LS clear, O 2sat 90-94%\n Action:\n Changed to hi flow mask with 60% Fio2, and weaned down Fio2 to 40%,\n serial cardiac enzymes x2 sent.\n Response:\n O 2sat remains 90-93% with 40% Fio2, Enzymes trending down.\n Plan:\n Pulm hygiene, wean Fio2 O2 as tolerates.\n" }, { "category": "Physician ", "chartdate": "2202-09-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390385, "text": "Chief Complaint:\n 24 Hour Events:\n - AM BNP was \n - Cardiac enzymes relatively stable, not decreasing\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:00 AM\n Metoprolol - 06:08 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 07:35 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 (98.4\n HR: 68 (67 - 81) bpm\n BP: 125/58(74) {104/49(65) - 138/92(97)} mmHg\n RR: 12 (11 - 16) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 45.2 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 540 mL\n 123 mL\n PO:\n TF:\n IVF:\n 540 mL\n 123 mL\n Blood products:\n Total out:\n 517 mL\n 330 mL\n Urine:\n 517 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23 mL\n -208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///29/\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 9.9 g/dL\n 123 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 47 mg/dL\n 108 mEq/L\n 146 mEq/L\n 32.4 %\n 16.6 K/uL\n [image002.jpg]\n 08:05 PM\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n Plt\n 333\n 364\n 373\n 320\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n TropT\n 0.75\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n Other labs: PT / PTT / INR:16.1/40.5/1.4, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 81 year old female with severe aortic stenosis, aflutter who is now s/p\n multiple bilateral embolic infarcts in MCA, ACA, PCA territories with\n mental status change and periodic hypoxia and tachypnea.\n .\n 1) Hypoxia - Patient desaturated two days ago into the mid 80s and\n responded to morphine, high flow mask, and respositioning. Likely\n flash pulmonary edema, especially given severe AS. Has tenuous\n hemodynamics and periodic desaturations may be her baseline. Over last\n 24 hours has been weaned from high flow mask, now on nasal cannulus.\n Continuing tx of underlying PNA and possible COPD flare may help reduce\n degree of hypoxia.\n -Continue tx of underlying PNA with ceftriaxone and azithro (today is\n day final day of 7 day course)\n -Continue prednisone taper, currently getting 60 mg: tomorrow taper\n down to 20 mg\n -nebs PRN\n -Not a surgical candidate for AS; likely will continue to have periodic\n desaturations, key will be to keep blood pressure controlled and keep\n off fluid, however can't be aggressive w/ diuresis given that she's\n preload dependant. Getting lopressor 5 mg IV q6 hrs. BPs have been\n 125 - 140.\n .\n 2) Troponin elevation - Initially elevated secondary to CVA and have\n been stable at .75. Following recent desat, enzymes further increased\n but have been stable at .85 with no significant change in CK-MB\n fraction. Likely experienced some demand ischemia secondary to\n increased work of breathing.\n -Cardiology is aware\n -No change in management given she is already on lovenox for CVA\n .\n 3) Altered Mental Status: Change from baseline; unclear etiology.\n Likely encephalopathy in setting of recent stroke, may also have a\n contribution from infection as well as steroid course. Unclear if\n improving.\n - continue to provide supportive measures s/p stroke (maintaining BPs)\n - treat pneumonia as above\n - continue steroid taper\n .\n 4) Recent CVA - Secondary to ischemic stroke, bilateral, affecting PCA,\n MCA, ACA. Most likely embolic from cardiac origin given widespread,\n bilateral distribution and hx of aflutter.\n -Echo did not show any clot\n -Holding on carotid duplex as would not change management; not a\n surgical candidate\n -Continue lovenox 40 mg \n -continue aspirin 81 mg daily\n -Touch base with Neuro re: outpatient MRI; long-term anticoagulation.\n .\n 5 Leukocytosis: Stable at 16, likely secondary to prednisone course.\n -Follow after steroids are tapered\n .\n 6) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke and prednisone course.\n -HISS w/ treatment for FSG >200.\n .\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n .\n 10) Dispo - to floor pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2202-09-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390386, "text": "Chief Complaint:\n 24 Hour Events:\n - brief family discussion, no acceleration of care, no decision on\n nutition or ICU status\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:07 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 08:00 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: 35.9\nC (96.6\n HR: 71 (61 - 77) bpm\n BP: 107/54(67) {107/53(67) - 139/74(86)} mmHg\n RR: 16 (11 - 16) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.5 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 519 mL\n 239 mL\n PO:\n TF:\n IVF:\n 519 mL\n 239 mL\n Blood products:\n Total out:\n 920 mL\n 235 mL\n Urine:\n 920 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n -401 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: ///33/\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 318 K/uL\n 10.0 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.6 mEq/L\n 40 mg/dL\n 109 mEq/L\n 149 mEq/L\n 32.6 %\n 13.7 K/uL\n [image002.jpg]\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n 01:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n 13.7\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n 32.6\n Plt\n 333\n 364\n 373\n 320\n 318\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n 0.8\n TropT\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n 134\n Other labs: PT / PTT / INR:14.5/37.2/1.3, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 81 year old female with severe aortic stenosis, aflutter who is now s/p\n multiple bilateral embolic infarcts in MCA, ACA, PCA territories with\n mental status change and periodic hypoxia and tachypnea.\n .\n 1) Hypoxia - Patient desaturated two days ago into the mid 80s and\n responded to morphine, high flow mask, and respositioning. Likely\n flash pulmonary edema, especially given severe AS. Has tenuous\n hemodynamics and periodic desaturations may be her baseline. Over last\n 24 hours has been weaned from high flow mask, now on nasal cannulus.\n Continuing tx of underlying PNA and possible COPD flare may help reduce\n degree of hypoxia.\n -Abx course complete, make sure D/C\n -Taper prednisone down to 20 mg\n -nebs PRN\n -Not a surgical candidate for AS; likely will continue to have periodic\n desaturations, key will be to keep blood pressure controlled and keep\n off fluid, however can't be aggressive w/ diuresis given that she's\n preload dependant. Getting lopressor 5 mg IV q6 hrs. BPs have been\n 125 - 140.\n .\n 2) Troponin elevation - Initially elevated secondary to CVA and have\n been stable at .75. Following recent desat, enzymes further increased\n but have been stable at .85 with no significant change in CK-MB\n fraction. Likely experienced some demand ischemia secondary to\n increased work of breathing.\n -Cardiology is aware\n -No change in management given she is already on lovenox for CVA\n .\n 3) Altered Mental Status: Change from baseline; unclear etiology.\n Likely encephalopathy in setting of recent stroke, may also have a\n contribution from infection as well as steroid course. Unclear if\n improving.\n - continue to provide supportive measures s/p stroke (maintaining BPs)\n - treat pneumonia as above\n - continue steroid taper\n .\n 4) Recent CVA - Secondary to ischemic stroke, bilateral, affecting PCA,\n MCA, ACA. Most likely embolic from cardiac origin given widespread,\n bilateral distribution and hx of aflutter.\n -Echo did not show any clot\n -Holding on carotid duplex as would not change management; not a\n surgical candidate\n -Continue lovenox 40 mg \n -continue aspirin 81 mg daily\n -Touch base with Neuro re: outpatient MRI; long-term anticoagulation.\n .\n 5 Leukocytosis: Stable at 13, likely secondary to prednisone course.\n -Follow after steroids are tapered\n .\n 6) Borderline glucose intolerance: Likely more elevated in setting of\n acute stroke and prednisone course.\n -HISS w/ treatment for FSG >200.\n .\n 7)FEN: replete lytes, NPO\n .\n 8)Propohylaxis: pneumoboots, lovenox\n .\n 9)code: DNR/DNI\n .\n 10) Dispo - to floor pending above; discussed prognosis with daughter;\n she needs a little bit of time to think about goals of care; will\n communicate with her again today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2202-09-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 390404, "text": "Subjective: Patient took an Italian Ice this a.m., RN.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 44.7 kg\n 46.5 kg ( )\n 19.2\n Pertinent medications: Dextrose 5% NaCl 0.45% @ 30mL/hr, metoprolol,\n others noted\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 01:57 AM\n Glucose Finger Stick\n 235\n 10:00 AM\n BUN\n 40 mg/dL\n 01:57 AM\n Creatinine\n 0.8 mg/dL\n 01:57 AM\n Sodium\n 149 mEq/L\n 01:57 AM\n Potassium\n 4.6 mEq/L\n 01:57 AM\n Chloride\n 109 mEq/L\n 01:57 AM\n TCO2\n 33 mEq/L\n 01:57 AM\n PO2 (arterial)\n 103 mm Hg\n 03:32 PM\n PCO2 (arterial)\n 36 mm Hg\n 03:32 PM\n pH (arterial)\n 7.52 units\n 03:32 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:32 PM\n Calcium non-ionized\n 8.8 mg/dL\n 01:57 AM\n Phosphorus\n 3.0 mg/dL\n 01:57 AM\n Magnesium\n 2.1 mg/dL\n 01:57 AM\n ALT\n 18 IU/L\n 03:31 AM\n Alkaline Phosphate\n 127 IU/L\n 03:31 AM\n AST\n 42 IU/L\n 03:31 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:31 AM\n WBC\n 13.7 K/uL\n 01:57 AM\n Hgb\n 10.0 g/dL\n 01:57 AM\n Hematocrit\n 32.6 %\n 01:57 AM\n Current diet order / nutrition support: Diet: NPO\n Assessment of Nutritional Status\n 81 year old female with severe aortic stenosis and aflutter who is now\n s/p multiple bilateral embolic infarcts in MCA, ACA, PCA territories\n with mental status change and periodic hypoxia and tachypnea. Patient\n remains NPO, and has been for 7 days now. Noted that team and family\n are still discussing and deciding on plan of care and care goals. \n RN, patient\ns family will likely not want to enterally feed patient. A\n swallow evaluation was attempted yesterday, however was unable to be\n completed due to patient not following commands and clamping mouth\n shut. MS seems improved today, however, and patient took a small\n amount of clear liquid po\n for RN. Recommend diet advancement versus\n tube feedings if within plan of care. Will follow up with plan for\n nutrition and goals.\n #\n" }, { "category": "Physician ", "chartdate": "2202-09-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 390408, "text": "Chief Complaint: CHF, Respiratory Failure, CVA\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 More alert this AM\n 24 Hour Events:\n On 2L NC overnight\n Allergies:\n Codeine\n Unknown;\n Ace Inhibitors\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 08:00 PM\n Ceftriaxone - 06:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:07 AM\n Other medications:\n per ICU resident\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Respiratory: No(t) Tachypnea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.6\nC (96\n HR: 74 (61 - 76) bpm\n BP: 107/54(67) {107/53(67) - 139/67(82)} mmHg\n RR: 12 (11 - 16) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.5 kg (admission): 44.7 kg\n Height: 60 Inch\n Total In:\n 519 mL\n 356 mL\n PO:\n TF:\n IVF:\n 519 mL\n 356 mL\n Blood products:\n Total out:\n 920 mL\n 295 mL\n Urine:\n 920 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -401 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, mental status\n improved today\n Labs / Radiology\n 10.0 g/dL\n 318 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 4.6 mEq/L\n 40 mg/dL\n 109 mEq/L\n 149 mEq/L\n 32.6 %\n 13.7 K/uL\n [image002.jpg]\n 03:31 AM\n 07:53 AM\n 03:07 AM\n 02:42 PM\n 03:32 PM\n 10:57 PM\n 05:09 AM\n 07:10 PM\n 02:57 AM\n 01:57 AM\n WBC\n 14.3\n 15.8\n 17.9\n 16.6\n 13.7\n Hct\n 30.1\n 32.3\n 32.7\n 32.4\n 32.6\n Plt\n 333\n 364\n 373\n 320\n 318\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 0.9\n 0.8\n TropT\n 0.72\n 0.83\n 0.85\n 0.87\n TCO2\n 30\n Glucose\n 134\n 119\n 116\n 132\n 123\n 134\n Other labs: PT / PTT / INR:14.5/37.2/1.3, CK / CKMB /\n Troponin-T:180/4/0.87, ALT / AST:18/42, Alk Phos / T Bili:127/0.8,\n Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n .H/O CARDIAC DYSRHYTHMIA OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n 81 year old female with multiple medical problems including diastolic\n heart failure, atrial flutter, severe AS, COPD, with new multiple\n embolic infarcts, hypoxia, RV hypokinesis, tachypnea.\n 1) Altered Mental Status: Improved today - but not back njear\n baseline. Continue\n 2) Increased Cough/O2 Requirement: Completed azithro course. CTX (\n of CTX). Tapering steroid dose. CHF as primary driver of acute\n changes\n 3) CHF:Managment difficult given AS and diastolic dysfunction. No\n further diuresis for the moment\n 4) Decreased urine output: Cr down today. Urine output stable.\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2202-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 389767, "text": "81 yo woman with prior CVA, COPD, severe AS and h/o adeno carcinoma adm\n with 2d h/o altered MS finally with obtundation and an increased O2\n requirement. Brought to Ed where altered MS. by Neuro to r/o\n stroke, CXR read as possible PNA adm to ICU. Here 97.5/ 86/ 126/66.\n Pursed lip breathing. Arouses to voice.\n Altered mental status (not Delirium)\n Assessment:\n Patient is drowsy, waking up to call, not following any commands,\n garbled speech, not responding to verbal commands, only says\n all\n the questions. Not opening eyes, moving rt side purposefully, lt hand\n flaccid, lt leg with draws to pain, PERL.\n Action:\n Neuro checks q4h, oriented to place and person with activities, SBP\n wnl.\n Response:\n Unchanged neuro status, waiting for MRI.\n Plan:\n Cont to monitor, MRI today.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, LS clear, non productive cough. O 2sat 94-98%\n Action:\n O2 down to 4L from 6L by NC, turned q2h, >30*, IVF 1L given, K+\n 40mmol replaced.\n Response:\n For CXR this morning, remains afebrile, O2 sat remains stable\n Plan:\n Pulm hygiene, chest PT, >30*, cont with anbx.\n .H/O cardiac dysrhythmia other\n Assessment:\n Patient ruling out for NSTEMI, cardiac enzymes wnl. Troponin 0.5 with\n labs at ,\n Action:\n 5 beat run of V tach noted, EKG done, seen by MICU MD, unchanged form\n previous one, K+ replaced.\n Response:\n Irregular HR with pvc\ns / pac\ns, team aware.\n Plan:\n Cont to monitor, repeat enzymes, support to patient and family.\n" }, { "category": "Radiology", "chartdate": "2202-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102991, "text": " 3:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for NGT position.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with AMS that cannot tolerate PO. Re-Placed NGT after first\n one broke.\n REASON FOR THIS EXAMINATION:\n Please assess for NGT position.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Assess for NG tube position.\n\n FINDINGS: A new NG tube has been placed with its tip in the stomach, although\n could be advanced 5-6 cm to more optimal position. Chronic basilar\n predominant fibrotic changes are stable with no new consolidation or\n pneumothorax. The heart size is unchanged.\n\n IMPRESSION:\n Interval placement of a new NG tube which could be advanced 5-6 cm, the tip is\n currently in the upper stomach. No acute cardiopulmonary findings.\n\n" }, { "category": "Radiology", "chartdate": "2202-09-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1102635, "text": " 8:53 PM\n CHEST (PA & LAT) Clip # \n Reason: 81 year old woman with altered mental status. Please evaluat\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with altered mental status. Please evaluate for pneumonia.\n REASON FOR THIS EXAMINATION:\n 81 year old woman with altered mental status. Please evaluate for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pneumonia, altered mental status.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the quality of the\n examination is improved. Slightly increased lung volumes with bilateral\n peripheral subtle reticulations indicating basal areas of fibrosis. The\n cardiac silhouette is at the upper range of normal, no evidence of\n overhydration or pulmonary edema is seen. No evidence of newly occurred focal\n parenchymal opacities.\n\n In the interval, a nasogastric tube has been placed. The tube has a normal\n course, but could be advanced by 5-10 cm, as its tip now projects over the\n very proximal parts of the stomach. No evidence of complications, notably no\n visible pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2202-09-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1101533, "text": " 4:57 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: evaluate for new stroke\n Admitting Diagnosis: PNEUMONIA\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with history of R MCA stroke found unresponsive with left\n sided deficits\n REASON FOR THIS EXAMINATION:\n evaluate for new stroke\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: 9:11 AM\n MR : Multiple small acut einfarcts in the cerebral and cerebella\n rhemispheres on boths dies, in the MCA and PCA territories, likely of embolic\n etiology- to correlate clinically.\n\n MRA Head: Patent major arteries with some atherosclerotic disease; no\n occlusio/ anueyrsm more than 3mm\n\n MRA Neck: Extremely suboptimal in quality due to motiona nd difficulty in\n interpreting; essentially non-interpretable for any useful info.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female patient, with history of right MCA stroke\n found unresponsive, with left-sided deficits, to evaluate for new stroke.\n\n COMPARISON: MR of the head done on and CT of the head done on\n .\n\n TECHNIQUE: MR of the head without and with IV contrast. 3D TOF MR angiogram\n of the head and contrast-enhanced MR angiogram of the neck with MIP\n reformations.\n\n However, this study is significantly limited due to patient's excessive motion\n and inability to cooperate.\n\n FINDINGS:\n\n MR OF THE HEAD: There are multiple areas of FLAIR hyperintensity in the\n periventricular and subcortical white matter in the frontal and the parietal\n lobes on both sides, these are increased, more specifically the one in the\n right periatrial region (series 7, image 14) and a small focus of increased\n FLAIR signal in the right cerebellar hemisphere (series 7, image 6).\n\n On the diffusion-weighted sequences, there are multiple small areas of\n restricted diffusion scattered in the frontal and the parietal lobes on both\n sides as well as in the left thalamus and a smaller one in the left occipital\n (Over)\n\n 4:57 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: evaluate for new stroke\n Admitting Diagnosis: PNEUMONIA\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lobe posteriorly (series 502, image 14); and multiple smaller areas of\n restricted diffusion in bilateral cerebellar hemispheres. Overall the etiology\n likely relates to an embolic source.\n\n These are new compared to the prior study of .\n\n On the post-contrast images, there are no foci of abnormal enhancement.\n\n The visualized portions of the paranasal sinuses are grossly clear.\n\n 3D TOF MR ANGIOGRAM OF THE HEAD: The major intracranial arteries of the\n anterior and the posterior circulation are patent, without focal flow-limiting\n stenosis, occlusion or aneurysm more than 3 mm within the resolution of MR\n angiogram.\n A1 segment of the right anterior cerebral artery is diminutive in caliber and\n likely related to hypoplasia and unchanged.\n The ventricles and the sulci are mildly prominent related to volume loss.\n Focus of narrowing, at the junction with the P1 and P2 segments, relates to\n the confluence of the posterior communicating artery and the P1 and the P2\n segments along with a fetal PCA variant. This is better visualized on the\n source images.\n\n\n CONTRAST- ENHANCED MR ANGIOGRAM OF THE NECK: This study is limited, due to\n excessive patient motion and difficulty in accurate contrast bolus timing. The\n origins of the arch vessels are grossly patent. The outlines of the carotid\n and vertebral arteries are visualized, accurate assessment for irregularity,\n focal stenosis is limited on the present study due to extremely suboptimal\n quality of the study.\n\n IMPRESSION:\n\n 1. Multiple small acute infarcts, diffusely scattered in the cerebral and\n cerebellar hemispheres, on both sides, in the ACA, MCA and the PCA\n territories, likely related to an embolic source. To correlate clinically.\n\n 2. Patent major intracranial arteries without focal flow-limiting stenosis,\n occlusion or aneurysm more than 3 mm within the resolution of MR angiogram\n with bilateral fetal PCA variant and hypoplastic A1 segment of the right\n anterior cerebral artery.\n\n 3. Suboptimal quality of the contrast-enhanced MR angiogram of the neck,\n which makes assessment inaccurate.\n\n (Over)\n\n 4:57 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: evaluate for new stroke\n Admitting Diagnosis: PNEUMONIA\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2202-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101529, "text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with possible CAP\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 81-year-old woman with possible community-acquired pneumonia.\n\n FINDINGS: There is no change since most recent prior study of . The appearance of a small right pleural effusion with adjacent\n atelectasis is very similar. Allowing for rotation, the appearance of the\n lung parenchyma is unchanged, with degree of emphysema. The cardiac\n silhouette is borderline in size. There is no pulmonary edema or\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2202-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102267, "text": " 2:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulm edema\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with AS, compromised respiratory status\n REASON FOR THIS EXAMINATION:\n ? pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: 81-year-old woman with aortic stenosis. Compromised respiratory\n status.\n\n IMPRESSION: AP chest compared to .\n\n Lungs are hyperinflated consistent with COPD. No pulmonary edema or\n pneumonia. Heart size top normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2202-09-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101824, "text": " 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute events\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with new desats\n REASON FOR THIS EXAMINATION:\n ? acute events\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: New desaturation.\n\n FINDINGS: Since the previous chest radiograph, appearances are unchanged with\n hyperinflation of the lungs and flattening of the hemidiaphragms suggesting\n COPD.\n\n Fibrotic changes in the lung bases bilaterally are mild and stable, possibly\n due to recurrent aspiration. No new consolidation, pneumothorax, or pleural\n effusion. The mediastinal silhouette is unchanged, with tortuosity of the\n aorta. Mild cardiomegaly.\n\n IMPRESSION: No acute cardiopulmonary findings. Hyperinflation consistent with\n COPD. Mild bibasilar fibrosis is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2202-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101416, "text": " 10:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with profound hypoxia\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest two frontal views.\n\n CLINICAL INFORMATION: 81-year-old female with history of profound hypoxia.\n\n COMPARISON: .\n\n FINDINGS: The patient's chin overlies the lung apices. The lungs are\n hyperinflated, with flattening of the diaphragms, consistent with chronic\n obstructive pulmonary disease. There is a small right pleural effusion with\n overlying atelectasis. Heart size appears mildly enlarged, which may also be\n secondary to a kyphotic position of the patient. The bones are diffusely\n osteopenic. The aorta is calcified. Multiple surgical clips are seen in the\n upper abdomen.\n\n IMPRESSION:\n\n Small right pleural effusion with overlying atelectasis. Mild cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2202-09-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1101422, "text": " 10:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH, ischemia (left hand weakness)\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for ICH, ischemia (left hand weakness)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc WED 12:09 PM\n No acute intracranial hemorrhage .Old right temporal infarct.If there is\n continued clinical concern for acute ischemia/infarction,recommended MRI with\n DWI for further assessment.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with altered mental status, to evaluate\n intracranial hemorrhage, ischemia (left hand weakness).\n\n TECHNIQUE: Contiguous axial images were acquired through the brain. No\n contrast was administered.\n\n COMPARISON: CT head done .\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect,\n midline shift or hydrocephalus. Again noted is hypodensity involving the\n right temporoparietal cortex, secondary to prior infarct. There is no\n evidence of acute major vascular territorial infarction. Again noted is a\n lacunar infarct in the right subinsular region. The ventricles and sulcal\n spaces appear slightly prominent, consistent with age-related atrophic\n changes. Calcifications of the cavernous portions of bilateral internal\n carotid arteries as well as thes vertebral arteries are noted.\n\n Visualized paranasal sinuses are normally aerated.\n\n IMPRESSION:\n\n 1.No evidence of acute intracranial hemorrhage or acute major vascular\n territorial infarction. If there is continued clinical concern for acute\n ischemia/infarct,an MRI with DWI would be more sensitive.\n 2.Right temporoparietal encephalomalacic changes related to prior infarct.\n\n" }, { "category": "Radiology", "chartdate": "2202-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102066, "text": " 3:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for volume overload\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p stroke, PNA\n REASON FOR THIS EXAMINATION:\n eval for volume overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Status post stroke, pneumonia, volume overload.\n\n FINDINGS:\n\n Comparison is made to .\n\n The lungs are hyperinflated. The aorta is tortuous. Heart is top normal in\n size. There is mild blunting of bilateral costophrenic angles. There is mild\n interstitial fibrosis at the lung bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2202-09-15 00:00:00.000", "description": "D OR J TUBE PLACEMENT, ALL INCL.", "row_id": 1103678, "text": " 11:00 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place Jejunostomy tube.\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * D OR J TUBE PLACEMENT, ALL INC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with severe aortic stenosis, old and recent strokes with\n limited mobility and cachexia.\n REASON FOR THIS EXAMINATION:\n Please place Jejunostomy tube.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with severe aortic stenosis, multiple strokes,\n limited mobility and cachexia. Request to place jejunostomy tube.\n\n The patient also status post partial gastric resection in for\n carcinoma. At the time of surgery, prejejunostomy procedure was performed\n where an efferent jejunal loop was tacked to the anterior abdominal wall by\n silk sutures and marked by surgical clips.\n\n CLINICIANS: Drs. , , and , the attending\n radiologist was present and supervised the entire procedure.\n\n ANESTHESIA: 25 mcg of fentanyl was administered intravenously at the\n beginning of the procedure. Topical and subcutaneous injection of 1%\n lidocaine were administered for local anesthesia.\n\n FINDINGS/PROCEDURE: After discussing the risks, benefits, and alternatives to\n the proposed procedure, written informed consent was given by the patient's\n doctor. The patient was brought to the angiography suite and placed supine on\n the angiography table. Preprocedural timeout confirmed the patient's identity\n using three patient identifiers, as well as the procedure to be performed.\n\n With fluoroscopic guidance, a nasogastric tube was placed into the region of\n the gastrojejunostomy, via a left nostril approach, after administration of\n local anesthesia using Hurricaine Spray and topical lidocaine gel.\n\n The upper abdomen was then prepped and draped in the usual sterile fashion.\n The patient's NG tube was then injected using Optiray and the efferent jejunal\n loop identified under fluoroscopy. Using fluoroscopic guidance and using the\n surgical clips which mark the efferent jejunal limb, a micropuncture needle\n was used to access the efferent jejunal limb. Jejunal position was confirmed\n by injection of contrast material and fluoroscopy. The micropuncture wire was\n then placed through the needle which was then exchanged for a micropuncture\n sheath. A 0.035 Glidewire was then placed through the micropuncture sheath,\n which was exchanged for a 5 French Kumpe catheter. Contrast material was\n injected through Kumpe catheter to confirm placement within a loop of jejunum\n distal to the gastrojejunostomy anastomosis. The Glidewire was then exchanged\n for 0.035 Amplatz Super Stiff wire, over which subsequent dilation of the\n (Over)\n\n 11:00 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place Jejunostomy tube.\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n overlying soft tissues was performed using subsequent 8, 10 and 12 French\n dilators. A 14 French peel-away sheath was placed over the Super Stiff wire.\n The internal dilator was removed, and a 14 French gastrojejunostomy\n catheter was placed through the peel-away sheath. The pigtail loop was formed\n and secured. The final tip of the catheter is positioned within a loop of\n jejunum efferent to the gastrojejunostomy, which was confirmed by injection of\n contrast material and fluoroscopy. The peel- away sheath was then removed.\n The tube was secured to the skin using a 0 silk suture and a Flexi-Trak\n device. A sterile dressing was applied.\n\n The patient's NG tube was then removed. The patient tolerated the procedure\n well without immediate complication.\n\n IMPRESSION: Successful placement of percutaneous 14 French jejunostomy\n tube, with internal 35 cm long catheter located within a loop of jejunum\n distal to the gastrojejunostomy anastomosis. Jejunostomy tube ready to be\n used.\n\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2103-03-08 00:00:00.000", "description": "Report", "row_id": 1552213, "text": "MICU nursing progress note 7A-1700\nNeuro - Alert, cooperative, using call light. Pt very impulsive, needs direction and limit setting. ? d/t high dose steroids. Restless. Zyprexa 5 with calming effect. Interpreter here but pt sleeping during interview and did not talk to her. MAE. OOB->chair most of day. Transfers independently, needs CG d/t impulsive behavior.\n\nResp - 3L NC, ABG 7.43/65/64. Sats mid 90s. Lungs clear, diminished throughout, occ exp wheezes. Nebs q 4 hrs. Non-prod cough. RR teens.\n\nCV - Hemodynamically stable. NSR/ST 70s->100s when restless. WBC 21 (on solumedrol). No edema. K and phos repleted.\n\nGI - Tolerating /low Na diet, appetite good. Soft formed brown stool x 4 this AM on commode. Insulin gtt off, lantis increased 60qAM, 20 qPM. SS insulin. Abd obese, +BS.\n\nGU - UOP adequate.\n\nSkin - intact. ID - T max 99.2. On azythromycin. + MSSA. Droplet precautions d/c'd as pt R/O influenza.\n\nSocial- No phone calls/visits today.\n\nPlan - Called out to floor, to be transferred.\n" }, { "category": "Nursing/other", "chartdate": "2103-03-07 00:00:00.000", "description": "Report", "row_id": 1552210, "text": "MICU nursing progress note 7A-7P\nResp - Received pt on BIPAP this AM, ABGs improving 7.35/90/70/52. Pt cooperative with care, not agitated. Placed on NC 2L, tolerating with Sats low 90s. ABGs remain stable, Sats low 90s. Increased FIO2 3L NC for PO2 52 with no significant change in Sats. Last ABG 7.38/66/55/41. Lungs diminished throughout with air movement, improved from this AM, occ faint exp wheezes. Alb neb q 2 hrs. + non-prod cough. RR 16-18. DFA negative for influenza A & B, droplet precautions d/c'd.\n\nNeuro - Very sleepy all day, easily aroused but falls asleep during conversation. Interpretation with Spanish speaking staff, pt oriented to person, place \"hospital\", reoriented to year. MAE, assists with repositioning. Coarse myoclonic tremors in hands which is reported to be baseline. Cooperative with care. Denies pain.\n\nCV - BP 127-140/65-75. On lopressor and vasotec. NSR 70s-80s, no ectopy. Mag and KCL repleted. No edema. CKs neg x 3.\n\nGI - NPO. Abd obese. +BS, no stool. Insulin gtt titrated to FSBS. Lantis 20U @ 11AM (pt takes at home). Will advance diet tonight.\n\nGU - UOP adequate. Pt ~ 1300 cc positive so far today.\n\nSkin - Intact.\n\nSocial - No calls/visits today. Pt lives with niece and nephew whom staff contact last night.\n\nPlan - Monitor resp status. Nebs q 2 hrs and prn. Q 1 hr FSBS, titrate insulin gtt. BIPAP prn. Goal Sat 90.\n" }, { "category": "Nursing/other", "chartdate": "2103-03-08 00:00:00.000", "description": "Report", "row_id": 1552211, "text": "Neuro: Pt is very agitated and jumps up and disconnects EKG. Replaced leads X4 times. No sedation given per Dr so that patient can be awake today to eat.\n\nCardio: NSR, no ectopy, afebrile, VSS. Pt is on insulin gtt and D5 at 50 cc q hr. Received 40 mg lasix at 0400. Labs sent at 0400. Two peripheral IV's both in AC's bilaterally. Pt does not keep arms down and pumps constantly beeping. RN in room staightening arms q1 hr during this shift.\n\nPulm: Pt on Bipap all night and sats 89% this am. Upper lobes clear, dim in bases. Strong cough, non productive.\n\nGI: Patient had a large glass of water last nite and tolerated well. Pos BS, no BM, positive flatus.\n\nGU: Foley QS clear yellow diursesing well this am\n\nSkin intact, no breakdown.\n\nPlan: Start patient on diet.\n" }, { "category": "Nursing/other", "chartdate": "2103-03-08 00:00:00.000", "description": "Report", "row_id": 1552212, "text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs given Q4 and held while patient on Bipap. Albuterol MDI also used in between Rx's as needed. Bs initially decreased with faint expiratory wheezes. Bipap started tonight with home settings Ipap 15, Epap 5, and 4lpm O2. Adequate O2 sats.\nImproved with Rx's. Bs clear bilaterally. RR 12 to mid teens.\nPlan: Continue with nebs Q4-Q6hr and Bipap as above.\n" }, { "category": "Nursing/other", "chartdate": "2103-03-07 00:00:00.000", "description": "Report", "row_id": 1552207, "text": "admission note: past med hx:asthma pt is on home o2(4 liters),obesity, restrictive lung disease, tracheal stenosis, tracheal malacia,s/p multiple intubations,tracheostomy.IDDM.CAD, appy,B12 deficiency\n\nALlergy: penicillin\n\npt c/o sob past few days, worsening. on admission to er sats 70 %\n In er pt received combivent times 3 , solumedrol iv, cxr ..mild chf ptr given lasix 20 mg iv.. good diuresis.pt was on bipap and sats improved to 95-100 % abg 7.18/pco2 136/ po2 113/ 53 tx to icu for possible intubation.\n\n arrive in icu on bipap. foley in draining clear yellow urine.pt speaks only spanish. according to er where spanish speaking med personal,pt disoriented. iv's in place r AC #20, L ac # 16 . pt started pulling at things and took bipap off. o2 at 3 liters nc on. requiring haldol 2.5 mg iv (with little effect) and ativan 1 mg iv which immediately calmed tp down. interpreter at bedside. pt refusing intubation, bipap aline etc. quetioning patient's reliability so family contact for permission.\nmultiple attempts to insert aline. l radial aline in place. pco2 is decreasing to 99. bipap reapplied and pt received an additional ativan .5 mg iv to enhance cooperation with bipap. gases improving pco2 decreased to 89.\n\nblood sugar greater that 500 by finger stick on arrival. insulin drip initiated .see careview insulin dripp titrated according to q 1 houly fingersticks.\n\nabddomen obese, positive bowel sounds\n\n gu: foley urine output dropeed to < 30 cc/hr for 3 hours . ho notified and fluid challenge of 250 ccns times one with good response uo 60 cc for nest hour.\n\nhr tachy to 114, on metroprolol 5 mg iv q 6 hours with good response. hr down to 70-90 nsr no ectopy. bp stable 140-98/\n" }, { "category": "Nursing/other", "chartdate": "2103-03-07 00:00:00.000", "description": "Report", "row_id": 1552208, "text": "RESPIRATORY CARE:\n\nPt admitted to MICU overnoc, for worsening resp status. Placed on noninvasive positive pressure ventilation, remained supported on vent for several hours. Pt taken off nippv for agitation. Administered Albuterol/Atrovent nebs. BS's diminished, exp wheezes. See flowsheet for rx times, further pt data\nPlan: Maintain support, bronchodilators as needed.\n" }, { "category": "Nursing/other", "chartdate": "2103-03-07 00:00:00.000", "description": "Report", "row_id": 1552209, "text": "Respiratory Care Note:\n Patient is off NIPPV today and has acceptable gas exchange at this time. vent left on s/b for nocturnal use as needed. She is receiving alb/atro nebs Q4 and albuterol MDIs Q2. BS with mild exp wheezing. Cough loose and non-productive. ABGs improving trends t/o day. Plan to continue monitoring and provide vent as neeeded.\n" }, { "category": "Radiology", "chartdate": "2103-03-09 00:00:00.000", "description": "CT TRACHEA W/O C W/RECONS", "row_id": 853041, "text": " 5:19 PM\n CT TRACHEA W/O C W/RECONS Clip # \n Reason: Please assess for airway obstruction\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with asthma, OSA, evidence of dynamic tracheal obstruction on\n CT 1 month ago, now desiring corrective procedure\n REASON FOR THIS EXAMINATION:\n Please assess for airway obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n This is a CT trachea study that is dated compared to previous study\n of .\n\n CLINICAL INDICATION: Asthma and obstructive sleep apnea. Evidence of dynamic\n tracheal obstruction 1 month ago. Please reassess airways.\n\n Helical CT of the central airways was performed without intravenous or oral\n contrast. Per the CT trachea protocol, the imaging acquisition extended to a\n few cm below the carina but did not include the entirety of the lung bases.\n Initially, imaging was performed with a standard dose technique at end\n inspiration. Subsequently, using a low-dose technique, an acquisition was\n performed during dynamic expiratory phase of respiration to evaluate for\n airway malacia. Additionally, the axial data will be used to create a series\n of multiplanar and 3-D images, which will be reviewed when the images become\n available to PACs.\n\n Images obtained during end inspiration demonstrate mild focal tracheal\n narrowing at the level of the thoracic inlet. At this level, the trachea has\n a somewhat triangular configuration and the lumen is narrowed to approximately\n 9 mm in diameter coronally. This compares to approximately 16 mm coronal\n dimension below this level. The area of narrowing is quite focal, beginning\n at the inferior aspect of the thyroid gland and extending for only\n approximately 2 cm in length.\n\n During the dynamic expiratory phase of respiration, there is a component of\n excessive collapse consistent with malacia. This results in a reduction of\n cross sectional area caliber from 111 millimeter squared at the area of\n stenosis during end inspiration to 33 millimeter squared during dynamic\n expiration.\n\n Assessment of the remaining portion of the airways demonstrates a normal\n caliber and contour of the remaining portion of the trachea as well as the\n proximal main bronchi. The lungs demonstrate minimal linear dependent\n opacities in the right lower lobe superior segment and are otherwise clear.\n\n There is no significant mediastinal or hilar lymphadenopathy. The imaged\n portion of the heart demonstrates a normal heart size and note is made of a\n small amount of coronary artery calcification.\n\n Additionally, there is slight disruption of the tracheal cartilage at the\n (Over)\n\n 5:19 PM\n CT TRACHEA W/O C W/RECONS Clip # \n Reason: Please assess for airway obstruction\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n level of the focal stenosis as noted previously.\n\n IMPRESSION:\n 1) Persistent focal tracheal stenosis at level of proximal thoracic inlet\n with associated component of malacia.\n\n 2) When available, comparison will be made to multiplanar and 3-D images, and\n an addendum can be issued to the report at that time.\n\n\n ADDENDUM: Multiplanar and 3d images have become available and are reviewed in\n conjunction with the axial images. They confirm the presence of focal tracheal\n stenosis with a significant component of malacia at the site of stenosis.\n\n" }, { "category": "Radiology", "chartdate": "2103-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852667, "text": " 4:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema, r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with severe asthma, diastolic CHF, and severe tracheal\n stenosis and tracheomalacia now in ED with hypoxia, dyspnea, and tachypnea\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema, r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe asthma, diastolic congestive heart failure, and severe\n tracheal stenosis and tracheomalacia, now with hypoxia, dyspnea, and\n tachypnea.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of . The\n cardiac silhouette is at the upper limits of normal in size. There are no\n focal parenchymal opacities. There is prominence of the pulmonary vasculature\n at the hila. No osseous abnormalities are present.\n\n IMPRESSION:\n\n Findings consistent with mild fluid overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-03-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 853020, "text": " 2:22 PM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for CHF/PNA\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old F w/ h/o asthma, chf, tracheomalacia, w/ persistent O2\n requirement despite steroids/abx\n REASON FOR THIS EXAMINATION:\n Please assess for CHF/PNA\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: History of asthma, CHF and tracheomalacia. Persistent oxygen\n requirement, despite steroid therapy. Assess for CHF and/or pneumonia.\n\n FINDINGS: Heart size is within normal limits. No typical configuration\n abnormality is present. Thoracic aorta and mediastinal structures are\n unremarkable. The pulmonary vasculature is normal. No signs of acute or\n chronic parenchymal infiltrates are present and the lateral and posterior\n pleural sinuses are free. Available for comparison is a previous chest\n examination dated . Increased perivascular haze and distended\n pulmonary vasculature was interpreted as overhydration of the patient at that\n time. The present restoration to normal pulmonary vascular appearance is\n consistent with this interpretation. At the present time, the chest findings\n are unremarkable and there is no evidence of CHF or acute infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-03-16 00:00:00.000", "description": "PERSANTINE MIBI", "row_id": 853604, "text": "PERSANTINE MIBI Clip # \n Reason: EVALUATION OF DYSPNEA AS ANGINAL EQUIV.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluation of dyspnea as anginal equivalent. Suspect coronary artery\n disease.\n\n SUMMARY OF THE PRELIMINARY REPORT FROM 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 Image Protocol: Gated SPECT.\n Resting perfusion images were obtained with thallium-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n Left ventricular cavity is normal.\n Rest and stress perfusion images reveal uniform tracer uptake throughout the\n myocardium.\n\n Gated images reveal normal wall motion.\n The calculated left ventricular ejection fraction is 67%.\n\n IMPRESSION: 1) Normal myocardial perfusion scan. 2) Normal left ventricular\n cavity size and function.\n /nkg\n\n\n , M.D.\n , M.D. Approved: MON 12:44 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": "ECG", "chartdate": "2103-03-07 00:00:00.000", "description": "Report", "row_id": 190286, "text": "Sinus rhythm\nModest nonspecific anterolateral T wave changes\nClinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent and further T wave\nchanges seen\n\n" }, { "category": "ECG", "chartdate": "2103-03-06 00:00:00.000", "description": "Report", "row_id": 190521, "text": "Sinus tachycardia\nModest diffuse ST-T wave changes - are nonspecific and may be within normal\nlimits\nSince previous tracing of , sinus tachycardia rate increased\n\n" } ]

[ { "category": "ECG", "chartdate": "2162-12-31 00:00:00.000", "description": "Report", "row_id": 279950, "text": "Sinus rhythm with tachycardia. R' pattern in lead V1. Narrow QRS interval.\nIncomplete right bundle-branch block. Diffuse anterior T wave inversions\nextending to the lateral wall and lead II. There is low normal voltage. No\nprevious tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1493608, "text": "Nursing Discharge Note\n Pt refused to be transferred to floor or stay the night. Dr in to speak with pt. Pt is competent, therefore he had her sign an AMA form. Assisted pt with getting dressed and into a wheelchair. Co-worker and HHA accompanied pt to front of hospital and into her HHA vehicle. HHA was to bring pt home and into bed. She will re-check on her tomorrow am.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1493605, "text": "MICU Admission Note 0500\n76 year old female admitted from ED with anemia, EKG changes.\n\nAllergies: Procainamide (shock), PCN (rash)\n\nMeds: Protonix, Vitamin A, C, E, B12, B6, Folic acid; glaucoma eye gtts, oxycodone prn for pain.\n\nCode Status: Pt. is DNR/DNI.\n\nPMH: myelodysplastic syndrome x 1 year; thrombocytopenia; glaucoma; HTN; hypercholesterolemia; arthritis; PUD; ectopic pregnancy; lyme dz ; S/P appy. Pt. quit smoking 30 yrs. ago; drinks occasionally.\n\nSocial hx: retired attourney. Pt. lives alone; fired her VNA. Brother lives in , NY; is aware that she is in the hospital and is driving here today. She is originally from .\n\nHPI: Pt. is transfusion dependent secondary to her MDS. She came to the ER last Saturday night with C/O fatigue; was transfused 1U platelets, then signed herself out AMA. She arrived in the ER again on Friday with further C/O SOB, fatigue, nausea. Labs drawn; Hct=11.6, WBC=3.8, Plt=8, EKG showed some ischemic changes (though CK-MB was negative). Pt. admitted to MICU for monitoring and multiple transfusions.\n\nNeuro: Pt. is AAOx3, possibly with some periods of confusion. She asks repeatedly about why she is here and expresses dissatisfaction with the hospital and this floor.\n\nResp: RR regular, lungs CTA, O2 sat 99% 2L NC.\n\nCV: HR is NSR in the high 90's with BP in the 110's/50-60's. + trace edema in bilateral ankles. Pt. denies CP at this time.\n\nGI: + BS x 4, abd. soft, not distended or tender. + flatus. No BM this shift.\n\nGU: Pt. voids in bedpan. Small amt. dk. yellow urine x 1 this shift.\n\nSkin: Pt. has multiple bruises scattered over her body. No abrasions/ulcers visible.\n\nPain: Pt. states that \"all of my bones ache.\" Presumed to be secondary to disease process. Dr. made aware. Oxycodone 10 mg given with some relief; Fentanyl patch ordered and applied. Pt. may benefit from chronic pain consult if her stay is long enough.\n\nPlan: continue to assess for CP; continue transfusions as ordered; monitor labs; pain assessment/management; D/C planning.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1493606, "text": "MICU NSG Discharge Note:\n Pls refer to nsg admission note for HPI and PMH. Pt has allergies to PCN-rash and Procaine-shock. Pt is a DNR/DNI. Since admission to , pt has been transfused with 3 u PRBC and 1 U pooled plts. Her f/u CBC was within baseline levels. No s/sx active bleeding. EKG changes have resolved. Pt has no c/o CP or SOB (except with exertion). Lungs CTA. She refuses to wear NC oxygen but sp02 is 97% on RA. Pt tollerating PO well and swallows medications without difficulty. Pt voids easily in bedban for amber, concentrated appearing clear urine. Pt complains of generalized bone pain, on admission pt was given 10 mg of oxycodone and started on a fentanyl patch with good relief. 10 mg oxycodone administered at 12 N with similar effect--pt to be discharged home on oxycodone only as this worked well for her in past. Fentanyl patch d/c'd.\n\nDispo: Unable to convince pt to consent to VNA services after discharge. She has hired a private HHA and does not wish to have any other services. Attending aware. Her brother is in transit from and will transport her home when he arrives. Pt has been made aware of all discharge orders, purpose and use of discharge meds and numbers to call if she feels worse.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1493607, "text": "MICU NPN addendum:\n Dr. paged and made aware that pt is refusing all services. Team to contact pts private physician/heme onc MD and clear d/c home with them. Care coordinator ( ) meeting with patient now to reinforce what services are available.\n" } ]

[ { "category": "Radiology", "chartdate": "2138-03-31 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1232463, "text": " 1:31 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please evaluate for venous thrombosis\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with lupus nephritis, worsening LE edema, hypercoagulable,\n concern for clot\n REASON FOR THIS EXAMINATION:\n please evaluate for venous thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening lower extremity edema in this hypercoagulable patient\n with a history of lupus.\n\n COMPARISON: None available.\n\n FINDINGS: Waveforms in the common femoral veins are symmetric bilaterally\n with appropriate responses to Valsalva maneuvers. In both lower extremities,\n the common femoral, proximal greater saphenous, superficial femoral, and\n popliteal veins are normal with appropriate compressibility, wall-to-wall flow\n on color Doppler analysis, and response to waveform augmentation. Normal\n compression is also present in the posterior tibial and peroneal veins\n bilaterally.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-31 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1232443, "text": " 11:32 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for expansion of perinephric hematoma.\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with lupus nephritis, perinephric hematoma after bx,\n worsening pain and worsening kidney function\n REASON FOR THIS EXAMINATION:\n please evaluate for expansion of perinephric hematoma.\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine 1.8\n ______________________________________________________________________________\n WET READ: YGd MON 7:45 PM\n Overall stable large right perinephric hematoma. Residual renal\n pseudoaneurysm cannot be assessed on this noncontrast exam. Stable large\n right RP hematoma. Interval resolution of pleural effusions. Recommend\n continued close monitoring of Hct. Unchanged marked anasarca. Splenic\n microcalcifications could be related to prior granulomatous disease such as\n histoplasmosis or TB. - dw Dr. by x at 7p on \n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\n\n DATE: .\n\n COMPARISON: , .\n\n CLINICAL INDICATION: 28-year-old woman with lupus nephritis, perinephric\n hematoma after biopsy, worsening pain and worsening kidney function. Please\n evaluate for expansion of perinephric hematoma.\n\n TECHNIQUE: Axial images of the abdomen and pelvis were obtained without the\n use of intravenous contrast. Coronal and sagittal reformatted images were\n constructed.\n\n TOTAL EXAM DLP: 898.22 mGy-cm.\n\n FINDINGS:\n\n ABDOMEN:\n\n Redemonstrated is the perinephric hematoma, which extends along the\n retroperitoneum into the pelvis, along the iliopsoas muscle. This is stable\n from the prior examination measuring approximately 3.3 cm in the largest\n perinephric component near the inferior pole and 15.2 x 7.4 x 13.8 cm in\n transverse, AP, and craniocaudal dimensions respectively (previously 15.6 x\n 7.8 x 13.7 cm). The perinephric and retroperitoneal hematoma remains high in\n density without liquefied component or significant surrounding inflammatory\n changes to suggest superimposed infection. Evaluation of the lower pole\n partially treated pseudoaneurysm is limited by lack of intravenous contrast.\n Again, there is mass effect on the right kidney with anterior displacement.\n There is no hydronephrosis. There is also mass effect and narrowing of the\n (Over)\n\n 11:32 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for expansion of perinephric hematoma.\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IVC.\n\n Multiple splenic calcifications are consistent with sequelae of prior\n granulomatous disease. The patient is status post cholecystectomy without\n obvious intra or extra-hepatic biliary dilatation. The liver, adrenal glands,\n left kidney, and pancreas have a grossly unremarkable unenhanced CT\n appearance. There is no mesenteric or retroperitoneal adenopathy. Small\n periaortic retroperitoneal nodes are visualized. There is no free fluid in\n the abdomen.\n\n Bilateral small pleural effusions previously present have resolved. Bilateral\n bases demonstrate linear strands of atelectasis. There is a 5.5 mm nodular\n opacity at the left base, likely atelectatic change, given the appearance in\n this region on prior CT examinations. The heart is at the upper limits of\n normal in size. There is no pericardial effusion.\n\n PELVIS:\n\n Again, the retroperitoneal bleed extends along the iliopsoas muscle into the\n pelvis. The bladder, uterus and rectum are unremarkable. There is no free\n fluid. There is no pelvic adenopathy. Inguinal lymph nodes measuring up to\n 12 mm are noted, likely reactive.\n\n There is persistent diffuse subcutaneous anasarca.\n\n Osseous structures within the proximal right femur, extending from the femoral\n neck into the proximal femoral shaft to the intertrochanteric region, there is\n a 6.2 cm lytic lesion with multiple internal osseous septations. There is no\n scalloping of the cortex. The lesion appears to be confined within the\n medullary space. The inferior aspect of the lesion is incompletely imaged.\n\n IMPRESSION:\n\n 1. Stable large perinephric/retroperitoneal hematoma without evidence of\n superimposed infection.\n\n 2. Probable residual left lower pole renal pseudoaneurysm is not evaluated on\n this non-contrast examination.\n\n 3. Diffuse marked anasarca.\n\n 4. Resolution of small bilateral pleural effusions with basilar atelectasis.\n A 5.5 mm nodular opacity at the left base likely represents resolving\n atelectatic change; however, attention on followup is warranted.\n\n 5. 6.2 cm lytic lesion in the right proximal femur is incompletely imaged.\n (Over)\n\n 11:32 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for expansion of perinephric hematoma.\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n This appears nonaggressive without cortical thinning/breakthrough.\n Differential considerations include fibrous dysplasia, unicameral bone cyst or\n chondromyxoid fibroma, although this is not expansile. For complete extent of\n the lesion, consider femoral radiographs.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-24 00:00:00.000", "description": "MRA BRAIN W/O CONTRAST", "row_id": 1231563, "text": " 5:26 PM\n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: dissection? occlusion/stenosis\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n Contrast: GADAVIST Amt: 9\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with acute onset vertigo and nystagmus, history of SLE\n REASON FOR THIS EXAMINATION:\n dissection? occlusion/stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 28 year old woman with acute onset vertigo and nystagmus,\n history of SLE.\n\n COMPARISON STUDY: None.\n\n STUDY: MRI head without and with contrast. MRA head without contrast and MRA\n neck with contrast.\n\n TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, gradient echo and\n diffusion-weighted images were obtained of the brain prior to administration\n of contrast. Axial T1 and axial MPRAGE images with coronal reconstructions\n were performed of the brain after contrast administration. 3D TOF MR\n angiography of the head was performed. Axial T1 weighted fat saturated images\n were obtained through the neck to rule out dissection. MRA neck was performed\n after intravenous administration of contrast using bolus tracking technique.\n MIP reformations were performed.\n\n The MRA Neck study is suboptimal due to poor timing of the bolus.\n\n FINDINGS:\n\n MRI HEAD:\n\n There is no evidence of acute infarct, intracranial hemorrhage or\n space-occupying lesion. The ventricles, extra-axial CSF spaces and cortical\n sulci appear normal.\n\n Brainstem and cerebellum appear normal. There is no abnormal leptomeningeal or\n parenchymal enhancement.\n\n The major intracranial vascular flow-voids are preserved. Visualized paranasal\n sinuses and mastoid air cells are clear. Orbits are unremarkable.\n\n MRA HEAD:\n\n The arteries of the anterior circulation including bilateral intracranial\n internal carotid arteries, anterior and middle cerebral arteries appear\n normal.\n\n (Over)\n\n 5:26 PM\n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: dissection? occlusion/stenosis\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n Contrast: GADAVIST Amt: 9\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The arteries of posterior circulation including bilateral vertebral arteries,\n basilar and posterior cerebral arteries appear patent.\n\n There is no evidence of focal flow limiting stenosis, occlusion or aneurysm\n greater than 3 mm.\n\n MRA NECK. Three-vessel aortic arch is noted. The origins of the great vessels\n and vertebral arteries are patent. Bilateral common, internal and external\n carotid arteries and cervical vertebral arteries appear normal.\n\n There is no evidence of focal stenosis, occlusion or dissection.\n\n IMPRESSION:\n 1. No acute infarct or hemorrhage.\n 2. No evidence of focal flow-limiting stenosis, occlusion, dissection or\n aneurysm larger than 3 mm in the major arteries of head and neck. The MRA neck\n study is suboptimal due to poor timing of the bolus and significant venous\n contamintaion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1231314, "text": " 12:33 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New left CVL placement\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with new left sided right CVL, old on right\n REASON FOR THIS EXAMINATION:\n New left CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess new line.\n\n Comparison is made with prior study .\n\n New left IJ catheter tip is at the cavoatrial junction. There is no\n pneumothorax. Right IJ catheter tip is in the IVC. There are low lung\n volumes. There is mild-to-moderate cardiomegaly. There is mild vascular\n congestion. Small bilateral pleural effusions are larger on the right side.\n Bibasilar atelectases are larger on the right side.\n\n Position of lines was discussed with Dr. by phone on at\n 1:50 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2138-03-23 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1231397, "text": " 1:37 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: infectious source? traumatic AVM? infected hematoma?\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 y/o F with hx lupus nephritis, nine days s/p renal biopsy performed for\n worsening creatinine/proteinuria, complicated by severe RP bleed now with\n stable HCTs but worsening pain\n REASON FOR THIS EXAMINATION:\n infectious source? traumatic AVM? infected hematoma?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\n\n DATE: .\n\n COMPARISON: Outside CT .\n\n CLINICAL INDICATION: 28-year-old female with history of lupus nephritis, nine\n days status post renal biopsy performed for worsening creatinine/proteinuria\n complicated by severe retroperitoneal bleed. Now stable hematocrit but\n worsening pain. Infectious source, traumatic AVM, infected hematoma?\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained without\n the use of oral contrast after the uneventful intravenous administration of\n 100 mL Visipaque. The patient was also hydrated given creatinine of 1.5.\n Coronal and sagittal reformatted images were constructed.\n\n TOTAL EXAM DLP: 833.72 mGy-cm.\n\n FINDINGS:\n\n ABDOMEN:\n\n There is a large right perinephric and retroperitoneal hematoma extending into\n the pelvis. Compared to the prior examination, this has enlarged, now\n measuring 15.6 x 7.8 x 13.7 cm in AP, transverse and craniocaudal dimensions.\n The immediate perinephric component has also slightly increased in size.\n There is a heterogeneous region in the lower pole of the left kidney with a\n central high-density region measuring approximately 1 cm (2:41). This\n high-density lesion was seen to be low in density on the outside unenhanced\n CT, suggesting probable residual pseudoaneurysm. The retroperitoneal hematoma\n is causing mass effect with displacement of the right kidney anteriorly.\n There is also mass effect on the IVC, which is compressed but patent.\n\n Multiple calcifications are present within the spleen. The patient is status\n post cholecystectomy. There is no intra- or extra-hepatic biliary dilation.\n The liver, adrenal glands, left kidney, and pancreas are grossly unremarkable.\n There is no mesenteric or retroperitoneal adenopathy. No pneumoperitoneum.\n Bowel loops are nondilated.\n (Over)\n\n 1:37 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: infectious source? traumatic AVM? infected hematoma?\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There are trace bilateral pleural effusions and basilar atelectasis. The\n heart is at the upper limits of normal in size. There is no pericardial\n effusion.\n\n PELVIS:\n\n Please see above for retroperitoneal hematoma findings. The bladder is\n decompressed with a Foley catheter with air within the bladder likely related\n to instrumentation. The uterus and rectum are grossly unremarkable. There is\n a small amount of free fluid in the pelvis. Bowel loops in the pelvis are\n unremarkable.\n\n There is generalized marked anasarca.\n\n There are no destructive osseous lesions.\n\n IMPRESSION:\n 1. Interval enlargement of the perinephric and retroperitoneal hematoma when\n compared to the examination. Correlation with serial\n hematocrits recommended. No evidence of liquified component or superimposed\n infection.\n 2. Approximately 1-cm area of enhancement within heterogeneous region in the\n lower pole of right kidney likely relates to residual pseudoaneurysm.\n 3. Marked anasarca.\n\n Results were discussed with Dr. by Dr. on at 1700 via\n telephone.\n\n" }, { "category": "ECG", "chartdate": "2138-03-27 00:00:00.000", "description": "Report", "row_id": 246196, "text": "Sinus rhythm. Single ventricular premature beat. Low voltage across the\nlateral precordium. Left ventricular hypertrophy.\n\n" }, { "category": "ECG", "chartdate": "2138-03-22 00:00:00.000", "description": "Report", "row_id": 246197, "text": "Sinus tachycardia. Left ventricular hypertrophy with lateral ST-T wave\nabnormalities. Poor R wave progression. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2138-03-22 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1231287, "text": " 7:58 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: please evaluate DOPPLER ultrasound for parenchymal disease o\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman s/p cholecystetomy with acutely rising LFTs\n REASON FOR THIS EXAMINATION:\n please evaluate DOPPLER ultrasound for parenchymal disease or portal vein\n thrombus\n ______________________________________________________________________________\n WET READ: EHAb SAT 9:14 AM\n 1. Normal liver Doppler examination.\n 2. No intra- or extra-hepatic biliary ductal dilation.\n 3. Mild splenomegaly and splenic calcifications.\n 4. Right perinephric hematoma, better seen on recent CT.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old female status post cholecystectomy with rising liver\n enzymes.\n\n COMPARISON: Outside hospital CT and ultrasound dated .\n\n TECHNIQUE: Transabdominal grayscale and duplex Doppler ultrasound examination\n of the right upper quadrant was performed.\n\n FINDINGS: No focal liver lesions are detected. There is no intra- or\n extra-hepatic biliary ductal dilation. The patient is status post\n cholecystectomy. The spleen measures 14.3 cm and contains multiple punctate\n echogenic foci, consistent with calcifications seen on recent prior CT.\n\n The left kidney measures 14 cm and does not demonstrate hydronephrosis,\n stones, or large masses. The right kidney measures 14.4 cm. The right kidney\n demonstrates a complex heterogeneous appearance, which is consistent with\n perinephric hematoma seen on recent prior CT. No right hydronephrosis is\n seen.\n\n The right, middle, and left hepatic veins appear patent with normal waveforms.\n The main portal vein, posterior right portal vein, and anterior right portal\n vein are patent with normal waveforms. The main hepatic artery is patent with\n normal waveform. The splenic vein and inferior vena cava demonstrate normal\n waveforms.\n\n IMPRESSION:\n 1. Normal liver Doppler examination.\n 2. Splenomegaly with splenic calcifications, granulomatous disease.\n 3. No intra- or extra-hepatic biliary ductal dilation.\n 4. Perinephric hematoma, better seen on recent CT.\n (Over)\n\n 7:58 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: please evaluate DOPPLER ultrasound for parenchymal disease o\n Admitting Diagnosis: PERINEPHRIC BLEEDING\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2179-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858205, "text": " 5:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with h/o COPD and NSCLC s/p right pneumonectomy, now with\n trach/vent since . Presents with low grade temp and L sided chest pain.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, non-squamous cell lung cancer, right pneumonectomy. Low-\n grade temperatures and left-sided chest pain.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST, AP: There is persistent, complete opacification of the\n right hemithorax with resection of multiple ribs consistent with the previous\n history of right pneumonectomy. The left lung is clear, although the left\n costophrenic angle has been clipped off the film. The pulmonary vasculature\n on the left is within normal limits. The tracheostomy tube is in unchanged\n position.\n\n IMPRESSION:\n 1. Left lung appears clear without evidence of LVHF or focal opacity.\n 2. Stable postsurgical changes on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-04 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 858526, "text": " 7:25 AM\n UNILAT SUBCLAV Clip # \n Reason: SVC obstruction?\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n Contrast: OPTIRAY Amt: 65\n ********************************* CPT Codes ********************************\n * TRANSCATH PLCMT INTRAVAS STENT -51 MULTI-PROCEDURE SAME DAY *\n * PTA VENOUS -51 MULTI-PROCEDURE SAME DAY *\n * INTRO CATH SVC/IVC -59 DISTINCT PROCEDURAL SERVICE *\n * INTRO INTRAVASCULAR STENT PTA VENOUS *\n * SVC GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC LESS THAN 100CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with SVC obstruction\n REASON FOR THIS EXAMINATION:\n SVC obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64 year-old male with bilateral upper extremity swelling and\n documented narrowing of the superior vena cava on a CT scan of the chest dated\n . Please perform venography with possible stenting of the narrowed\n superior vena cava.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the staff radiologist, was present and\n supervising throughout. After the risks and benefits of the procedure were\n discussed in detail with the patient and his wife and written informed consent\n was obtained, the patient was placed supine on the angiography table. Both\n the patient's right arm and right groin were prepped and draped in the\n standard sterile fashion. Through the indwelling sheath present in the\n accessed right basilic vein, a right upper extremity venogram was performed.\n The revealed free passage of contrast into the right subclavian vein, the\n brachiocephalic vein, the superior vena cava, and the right heart. A focal\n web-like stenosis is present within the superior vena cava. No collateral\n vessels are present. Based on these diagnostic findings, it was decided that\n the patient would benefit from angioplasty with possible stenting. Therefore,\n our attention was turned to accessing the right common femoral vein.\n\n Through an anesthetized skin approach, the patient's right common femoral vein\n was accessed with a 19-gauge single wall puncture needle. After venous blood\n was aspirated, a .035 wire was advanced through the access needle,\n beyond the inferior vena cava filter, into the superior vena cava. The skin\n entry site was incised with a #11 blade scalpel. The access needle was\n replaced with a 7-French 35 cm long bright tipped angiographic sheath. Under\n direct fluoroscopic visualization, the sheath was advanced over the \n wire beyond the recovery IVC filter into the suprarenal inferior vena cava.\n After the inner dilator was removed, a balloon angioplasty catheter was\n advanced over the wire, through the angiogrpahic sheath, into the\n superior vena cava. Under direct fluoroscopic visualization, the SVC\n narrowing was dilated using a 10 mm x 4 cm balloon. The balloon angioplasty\n (Over)\n\n 7:25 AM\n UNILAT SUBCLAV Clip # \n Reason: SVC obstruction?\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n Contrast: OPTIRAY Amt: 65\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n catheter was then removed. There was persistent stenosis after angioplasty.\n Therefore, a 12 mm x 4 cm Nitinol smart stent was deployed across the\n previously described lesion within the superior vena cava. Following\n deployment, the stent was dilated throughout its length using the 10 mm\n balloon.\n\n A repeat cavogram was then preformed via injection of contrast through the\n accessed right basilic vein sheath. There was free and rapid passage of\n conrast into the right subclavian vein, the superior vena cava, and the right\n heart, without evidence of residual stenosis. At this time, the 7-French\n angiographic sheath was removed from the right common femoral vein. Manual\n pressure was held until hemostasis was achieved. A dry sterile dressing was\n applied. A final fluoroscopic spot film of the abdomen demonstrated the\n recovery IVC filter to be appropriately positioned. There was no evidence of\n filter migration. A final AP chest x-ray was obtained, demonstrating the\n stent to be positioned within the superior vena cava. At this time, the\n patient had a right basilic vein PICC line placed which is dictated under clip\n #. Following the procedure, the patient was returned to the medical\n intensive care unit in stable condition.\n\n COMPLICATIONS: None.\n\n MEDICATIONS: 1% Lidocaine. 75 micrograms of Fentanyl were administered in\n intermittent doses with continuous monitoring of vital signs by the nursing\n staff.\n\n CONTRAST: 35 cc of 60% Optiray 320.\n\n IMPRESSION: 1. Venography revealed patency of the right basilic, subclavian,\n and brachiocephalic veins with a focal web-like stenosis of the superior vena\n cava. There was passage of contrast beyond the stenosis into the right heart\n with no collateral vessels present.\n\n 2. Successful balloon dilation of the focal superior vena cava stenosis with\n a 10 mm balloon followed by deployment of a 12 mm x 4 cm Nitinol smart stent\n with good angiographic results and no residual stenosis.\n\n 3. Appropriately positioned Bard recovery infrarenal Nitinol IVC filter.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-04 00:00:00.000", "description": "PICC W/O PORT", "row_id": 858600, "text": " 2:45 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: ABX\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 64 year-old male with poor IV access and need for intravenous\n medications and blood draws. Please place PICC line.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. \n . Dr. , the staff radiologist, was present and supervising\n throughout. The patient was placed supine on the angiography table. His\n right upper extremity was prepped and draped in the standard sterile fashion.\n Since no suitable superficial vein was visible, ultrasound was used for\n localization of an appropriate vein. The right basilic vein was patent and\n compressible. The skin and subcutaneous tissues were anesthetized with 3 cc\n of 1% Lidocaine. Using ultrasound guidance, the right basilic vein was\n accessed with a 21-gauge micropuncture needle. Hardcopies of ultrasound\n images were obtained, before and after establishing an access. A .018\n guidewire was advanced through the access needle into the superior vena cava\n under fluoroscopic visualization. The skin entry site was incised with a #11\n blade scalpel. The access needle was exchanged for a 5-French micropuncture\n sheath with inner dilator. Based on the markers on the guidewire, it was\n determined a length of 35 cm would be appropriate. The PICC line was then\n trimmed to length and advanced over the guidewire, through the peel-away\n sheath, beyond the stent in the superior vena cava into the distal superior\n vena cava just above the right atrium. The guidewire and peel-away sheath\n were removed. The catheter was flushed, capped, and heplocked. It was\n secured to the skin using a statlock device. A dry sterile dressing was\n applied.\n\n FINDINGS: A final AP chest x-ray was obtained, demonstrating the tip of the\n catheter to be present in the superior vena cava beyond the SVC stent.\n\n COMPLICATIONS: None.\n\n MEDICATIONS: 1% Lidocaine.\n\n IMPRESSION: Successful placement of a 36 cm, 5-French dual-lumen PICC line\n via the right basilic vein. The tip of the catheter is present in the\n superior vena cava beyond the indwelling stent. The catheter is ready for\n immediate use.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-01 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 858212, "text": " 6:17 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please evaluate for both PE as well as SVC syndrome.\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with trach/vent after lung CA, also with h/o PE and IVC filter,\n p/w new L sided chest pain as well as severe new bilateral arm swelling.\n REASON FOR THIS EXAMINATION:\n Please evaluate for both PE as well as SVC syndrome.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp MON 8:18 PM\n no PE. SVC patent throughout without thrombus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung cancer status post pneumonectomy with history of PE, new left-\n sided chest pain and new bilateral arm swelling.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the lung apices to the\n lung bases were obtained before and after the administration of 100 cc of IV\n Optiray. Nonionic contrast was administered secondary to patient request.\n Coronal and sagittal reconstructions were performed.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial\n vasculature is well visualized down to segmental branches. No filling defects\n are identified. The superior vena cava is patent throughout without evidence\n of thrombus. As before, the proximal superior vena cava is compressed to a\n narrow slit-like lumen. There is occlusion of the left subclavian\n artery and vein, which is not changed since the prior exam. Numerous\n collaterals are visualized within the anterior chest. The right subclavian\n artery and vein appear patent. There is thickening of the walls of the arch\n vessels at their takeoffs from the arch, unchanged since the prior exam, which\n may be related to prior radiation changes.\n\n Patient is status post pneumonectomy with postoperative changes again noted in\n the right hemithorax, unchanged since the prior examination. Aortic arch\n calcifications are noted. Coronary artery calcifications are seen. The heart\n and pericardium are otherwise within normal limits. There is no pericardial or\n pleural effusion demonstrated. There is stable shift of the mediastinal\n structures towards the right. No pathologically enlarged axillary, hilar, or\n mediastinal lymph nodes are demonstrated.\n\n Lung window images demonstrate mild atelectatic changes noted at the left\n lower lobe. Additionally there is a tiny 3 mm pulmonary nodule noted within\n the left upper lobe which is stable since the prior examination. Patient is\n status post tracheostomy with tube in stable and satisfactory position. The\n airways are patent to the level of the segmental bronchi on the left side.\n\n In the visualized portion in the upper abdomen, the imaged spleen, kidneys,\n adrenal glands, liver, and gallbladder are all unremarkable.\n (Over)\n\n 6:17 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please evaluate for both PE as well as SVC syndrome.\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen. There has\n been interval resection of right-sided ribs.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n delineating the pulmonary arterial vasculature. They are of value 3.\n\n IMPRESSION:\n 1. No CT evidence of pulmonary embolism.\n 2. Stable right pneumonectomy changes.\n 3. Stable left upper lobe pulmonary nodule.\n 4. Small mediastinal lymph nodes, none of which meet criteria for pathologic\n enlargement.\n 5. Stable appearance of the superior vena cava which is patent throughout,\n but compressed proximally to a slit-like lumen.\n 5. Chronic occlusion of the left subclavian artery and vein with numerous\n vascular collaterals demonstrated within the anterior chest wall.\n\n These findings were discussed with Dr. at 9:00pm on .\n\n" }, { "category": "ECG", "chartdate": "2179-02-08 00:00:00.000", "description": "Report", "row_id": 105930, "text": "Technically difficult study\nIrregular rapid rhythm multifocal atrial tachycardia versus atrial fibrillation\nwith conversion to sinus rhythm\nLow QRS voltages in precordial leads\nClinical correlation is suggested\nSince previous tracing, irregular rhythm new\n\n" }, { "category": "ECG", "chartdate": "2179-02-05 00:00:00.000", "description": "Report", "row_id": 105931, "text": "Sinus rhythm. Compared to the previous tracing probably8 no significant change.\nThe suggestion continues to be that of pericardial effusion with pericarditis.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-02-04 00:00:00.000", "description": "Report", "row_id": 105932, "text": "Normal sinus rhythm, rate 83. Generalized low voltage. Subtle PR segment\nelevation in lead aVR with PR segment depression in leads II, III, aVF, V3-V6.\nJ point elevation with concave upward ST segment elevation in\nleads I, II, III, aVF and V3-V6. Pericardial effusion with pericarditis is to\nbe considered. Compared to the previous tracing of the PR segment\nchanges are marginally more pronounced. The ST segment elevations are\nessentially unchanged.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 105933, "text": "Sinus rhythm\nLow QRS voltages\nQT interval prolonged for rate\nPredominately inferolateral mild ST segment elevation\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2179-02-01 00:00:00.000", "description": "Report", "row_id": 105934, "text": "Sinus arrhythmia with sinus arrhythmia\nAtrial premature complex\nlow precordial lead voltages - is nonspecific\nSince previous tracing of , sinus bradycardia absent\n\n" }, { "category": "ECG", "chartdate": "2179-02-02 00:00:00.000", "description": "Report", "row_id": 105935, "text": "Sinus rhythm\nBorderline low QRS voltage - is nonspecific but clinical correlation is\nsuggested\nSince previous tracing of , probably no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 1463152, "text": "resp care\nremains /vented. presently on ac mode. was on psv mode of ps 18/peep 5/40% for a few hours, tolerated fairly well. no pmv trial as of yet today, awaiting wife's visit. awaiting mri/IR. rn sxned lg amt sputum. 's given q4h.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 1463153, "text": "addendum\nMRI cancelled as radiology feels will be unable to get good film of chest with vent. Pt to go to IR tomorrow for stenting. Per , keep propofol gtt on for pt comfort.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 1463154, "text": "Med with 4mg mso4 iv for dsg change. Sacral dsg change to . Old dsg with purulent drainage. Wound clean and red. Packed with duoderm gel on gauze.. ns w-d. Propofol gtt increased due to pt. c/o he can't relax/sleep. Suctioned once via trach for mod sputum. No vent changes on cmv ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-04 00:00:00.000", "description": "Report", "row_id": 1463155, "text": "MICU NPN 0000-0700\n\nNo major events overnoc. Pt very restless throughout the night. Plan is for pt to go to IR for SVC narrowing.\n\nNeuro: Pt on Propofol gtt @ 20mcg/kg/min. Pt is not sedated on this dose. He has dozed intermittently throughout the night but otherwise restless. He bangs on side rails for RN attention despite frequent reminders to use call bell which he always has access too. Pt c/o \"pain all over\" in which he was given morphine. Oriented x 3 (although has consistantly said it is initially and then able to correct himself). Pt is ordered for and may benefit from it to help aid in sleep. Would check with pt's wife to make sure he has been receiving this at the rehab hospital.\n\nResp: Vent settings ACx10/500/40/5. Sxned frequently for small amounts of yellow sputum. Pt c/o being SOB at times which resolves with suctioning. LS coarse on left side, diminished on Rt side.\n\nCV: hemodynamically stable. BP SB-SR, 54-83. No ectopy noted. K 4.0.\nBP 108-131/61-70. Hct stable @ 30.9. Heparin gtt infusing @ 1300u/hr PTT therapuetic @ 63.9.\n\nGI: NPO after midnoc for Stenting. Abdomen soft, non tender. +flatus. No stool. NO sliding scale requirements needed.\n\nGU: adequate u/o via foley 60-140cc/hr. Pt was negative 600cc @ midnoc. He is net negative 2 liters length of stay.\n\nDispo: REmain in MICU. Full Code\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-04 00:00:00.000", "description": "Report", "row_id": 1463156, "text": "Resp. Care Note\nPt remains and vented on settings as charted on resp flowsheet. Pt remained on PMV until about while wife was here, did well, speaking clearly. Pt rested off on on but very restless during the night. 's given q vent check, sxn for thick white secretions. cont current support, plan is for IR for SVC stent.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-04 00:00:00.000", "description": "Report", "row_id": 1463157, "text": "Resp Care\nPt remains on a/c-parameters noted. No wean this shift. Pt very agitated-on fentanyl and propofol. Taken to IR for stenting on SVC. Coarse breath sounds bilat. Suction for small amt of thick white secretions. MDIs as ordered. will continue mech vent and wean as .\n" }, { "category": "Nursing/other", "chartdate": "2179-02-02 00:00:00.000", "description": "Report", "row_id": 1463145, "text": "Respiratory Care:\n Pt. brought to EW from Rehab. with atypical C.P. He has a #8 portex trach. which was done here during one of his recent admissions due to prolonged vent.depend./resp. failure/pneumonia. Transferred to MICU with vent. support as he had at the rehab. A/C 500ml x 10, 40%, 5PEEP. Assisting over to about a rate of 15-20bpm. MDI's being given as ordered. Sx'ng thick yel.secretions in mod. amt.'s. BS-coarse, but clearing post sx'ng. Please see flow sheet under resp. for more details.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-02 00:00:00.000", "description": "Report", "row_id": 1463146, "text": "Admission Note\nPt admitted to MICU-A bed 791 @0145 from EW.\n\nExtensive PMH including: squamous cell lung carcinoma, c/p chemo and radiation and right pneumonectomy with perioperative PE...IVC filter placed, prostate cancer s/p radical prostatectomy. DM type 2, COPD, A-fib, TIA ', gout, GERD, OSA and unable to tolerate bipap, HTN, colonic polyps, ^cholest, basal cell carcinoma on back, sciatica, hx herpes zoster, multiple admissions for PNA, cataracts, bradycardia on amio, anemia with baseline Hct 28, stage 4 sacral , diastolic heart failure with last LVEF 55%, bronchitis resulting in prolonged resp failure requiring trach/PEG and sent to rehab.\n\nAllergies: Levofloxacin and benzos\n\nAdmit: Pt at when started to c/o left sided anterior CP that did not radiate. Brought to EW where concern for embolus or cardiac event. CT chest performed and negative...cardiac enzymes showing elevated trop 0.12, R/I MI but no evidence of EKG changes. Cards consulted and seen patient in EW.\n\nCV: HR 60-80's, NSR with tall T waves and occasional PAC's. BP 80-100/30's (known for labile hypotension, holding BB). PIVx2 left hand (left wrist site placed by EW, left hand site in place from rehab facility). Pt with bilateral 2+ upper arm edema. Pulses palpable.\n\nResp: Pt , vent-dependent. Rests on AC mode overnoc, arriving on AC 10/400/5peep/40%. During day usually switches to 25/5 40%.\nBBS clear, minimal secretions.\n\nNeuro: Pt , following commands and mouthing words to communicate. Per wife patient has been agitated and confused at , receiving haldol until this past week where his mental status has greatly improved. Still confused at times and lucid, but easily reoriented and no longer agitated. Restless in bed d/t being uncomfortable. Turns and positions self. Pt has long history of anxiety and chronic back pain controlled by morphine, fentanyl patch and haldol. Hold benzo d/t increased agitation/confusion.\n\nGI/GU: Abdomen soft, BS present. LUQ PEG clamped, Pt NPO. On Lansoprazole. Foley cath intact draining adequate amounts of clear yellow urine. No BM.\n\nEndo: Type 2 DM...BS 66 in EW, 54 once to unit. Given 1 amp D50% with post BS 101. Continue to assess closely. While patient remains NPO, only give half dose of glargine.\n\nSkin: Stage 4 sacral on , appears to tunnel. Wet-to-dry dressing being applied QD. Will consult wound care specialist.\n\nSocial: Wife present at time of transfer, very supportive and will return to visit patient this evening. Pt priorly DNR, but team has discussed with wife , and with recent progress, wants resuscitation...Full Code.\n\nPlan: Cycle cardiac enzymes\n EKG this am\n Plans to return to once complete cardiac eval.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-05 00:00:00.000", "description": "Report", "row_id": 1463160, "text": "npn 7p-7a (see carevue flownotes for objective data)\n\ndx: s/p STENT to SVC, rt groint approach\n\nneuro/c-v:\npt very restless/anxious these past couple days; last night pt hypertensive, hrt rate sinus arrhythmia vs frequent PAC's; gave pt Morphine Sulfate, 2 mg IV at approx 12a, pt Significantly improved, more restful, hrt rate became Regular, no PAC's; b/p came down from syst 160's to sys 120's/110's; notable was Fentanyl patch over rt shoulder/ area---thus likey very ppor absorption (? pts escalation over previous 48 hrs d/t w/drawal?)\n gradually able to wean from propofol after Morphine given; a.m. haldol given at 06:00; new Fentanyl patch also applied at 06:00, in preparation for d/c'ing propofol;\n\n\nheparin gtt off approx 2p prior to STENTing, coumadin not restarted last eve d/t pt's elevated PT/INR; may restart today;\n\nresp:\nremained on A/C overnight, reportedly is on A/C overnight at rehab, and PS during day; suctioned approx q 3 hrs for small amt yellowish-whitish/opaque return; O2 sats in 90's overnight, 97% at writing of this note;\n\ng-i:\nhad large amount very soft/liquid med stool at approx 12a; glargine on hold until tube feeds restarted;\n\ng-u:\nurine output adequate via patent foley;\n\nskin:\n dressing d/i; scattered fragile appearing sites on arms;\ndespite frequent re-positioning by staff, pt \"scoots\" self to preferred position;\n\naccess:\nnew Rt a.c. dbl PICC placed yesterday in IR; patent;\nalso 2 periph IV's left hand/wrist;\n\nsocial:\nwife present last eve; left approx 21:00;\n\nPLAN:\nPlan is for pt to return to today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-05 00:00:00.000", "description": "Report", "row_id": 1463161, "text": "Resp Care\nPt remains on A/c-parameters noted. No wean this shift. Pt scheduled to go to rehab. Coarse breath sounds bilat. Suction for thick tan secretions. MDIs as ordered. Pt still a bit agitated, but improved.\nWill continue mech vent and wean as .\n" }, { "category": "Nursing/other", "chartdate": "2179-02-05 00:00:00.000", "description": "Report", "row_id": 1463162, "text": "NPN 0700-1900;\n\nPT MENTAL IMPROVED. AOOX3 COOPERATIVE WITH CARE RESTRAINTS AND SITTER D/C' HAS NOT ATTEMPTED TO GET OOB ALTHOUGH AT TIMES RESTLESS AND MOVES FREELY AROUND BED. UNABLE TO GET PT OOB TO CHAIR AS UNABLE TO LOCATE FOAM SEAT FOR CHAIR PT WITH STAGE 3 ULCER ON .\n\nNEURO AOOX1 MAE TO COMMAND MUCH CALMER AFTER PT REALISED THAT PROCEDURE WAS DONE YESTERDAY.\n\nRESP LUNG SOUNDS COARSE. ABSENT ON SATS 99-100% RR 1826 SUCTIONED Q2 FOR THICK WHITISH YELLOW PT USING FOR ORAL SUCTION.PT PLACED ON PASSE MUIR WITHGOOD EFFECT.\n\nCVS; STABLE PLEASE SEE CAREVUE FOR DETAILS C/O OF CP SHORTLY AFTER PROPOFOL TURNED OFF.12LEAD SHOWED NO CHANGE PT SETTLED WITH OUT TREATMENT .\n\nGU; PASSING MOD AMOUNT OF URINE VIA FOLEY.\n\nGI; T/F RESTARTED AT 40 MLS TO ADVANCE TO GOAL.POS BS PASSING GOOD AMOUNTS OF SOFT GOLDEN STOOL.INTO BEDPAN.\n\nBS ON RISS.\n\nSORE ON DRESESS WITH DUODERM GEL AND NSW-D X2.BASE YELLOW.\nI.V'S REMOVED FROM LT HAND PICC PATENT.HAND UNDER BUTTERFLY WEEPING TAGADERM PLACED OVER SITES.\n\nSOS; WIFE INTO VISIT AND UPDATED WITH PRESENT PLAN OF CARE PT HAS LOST BED AT BUT CASE MANAGER IS TRYING TO OBTAIN ANOTHER BED.WIFE \"LOVED \" AND WANTS PT TO RETURN THERE.\n\nA/P;SUPPORT PT AND PREPARE FOR TRANSFER TO REHAB WHEN BED AVAILABLE.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-02 00:00:00.000", "description": "Report", "row_id": 1463147, "text": "NPN 0700-1900\nNeuro: Pt calm and cooperative all day on scheduled meds s prns. Moves about in bed turning from side to side. Had passy muir valve on for short period, communicated well, oriented x3. No c/o pain.\n\nResp: Pt placed on PS in am (usu on PS during day at rehap). After few hours, pt became tachypneic c rr up to 40. Sx and encouraged DB, but returned to AC 500 x10, 5 peep, and 40% fio2. Sats 96-100. Overbreathing the vent c rate 16-21. Sx variable times for mod amt thick, tan secretions\n\nCV: HR 56-78, SB to NS, no ectopy. BP 96/41 - 120/69. Tmax 98.6. Transfusing one unit pc started at 1600 for hct 29. Team wants post transfusion hct and other labs at . Latest troponin .12 at 1300, down from .14. Seen by cardiology. No cath needed at this time. No c/o chest pain.\n\nGI: Abd soft, +BS. One med, , soft stool, OB+. NPO all day for potential studies, team will start TF.\n\nGU. U/o qs, 50-60mls/hr. Pt has large amt upper arm edema.\n\nEndo: Pt usu on am glargine, held due to low FS of 60. FS low, received Dextrose 50% 25 gms x2.\n\nSkin: Large, deep pressure sore on , viewed by . Wound looks clean c mod amt serous dng. For dsg, used duoderm gel inside applied with sterile Qtips, followed by wet saline gauze packing, reapplied after pt's bm. Pt has L elbow abrasion covered c duoderm. Has a # of healing skin tears.\n\nSocial: Wife visiting this eve.\n\nPlan: Post hct and chems at . Start TF, monitor FS, Monitor resp status and Sx as needed. Monitor neuro status for irritability.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-02 00:00:00.000", "description": "Report", "row_id": 1463148, "text": "resp care\nremains /vented in ac mode. trial of ps today, tolerated fairly well but developed tachypnea,?anxiety vs secretions. pmv placed today by speech, able to speak in full sentances, some gurgling in upper airway which pt was unable to clear completely on own. will attempt pmv with wife present. 's given q4h.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 1463149, "text": "Resp Care: Pt continues and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 98% with positional leak in cuff; bs insp squeaks/wheeze, rx with albuterol/atrovent , sxn thick yell secretions, rsbi 93, will cont slow psv wean per HO.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-06 00:00:00.000", "description": "Report", "row_id": 1463163, "text": "Resp Care: Pt continues and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 96% with positional cuff leak; bs rhonchorous/few squeaks, rx with albuterol/atrovent/flovent, sxn thick white secretions, rsbi 123, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-06 00:00:00.000", "description": "Report", "row_id": 1463164, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: s/p SVC STENT;\n\nPt not discharged to yesterday Friday d/t pt here longer than 4 days, therefore lost his bed at .\n\nneuro/social:\npt remains off propofol; on RTC Haldol for h/o anxiety d/o--pt becomes unsafe to self re pulling at trach at times, and sitting upright in bed causing separation of trach to vent; also receives prn 1 mg haldol occasionally;\n fent patch on chest wall over warm fleshy area for good absorption;\n pt 'better' when wife present; seems more relaxed, smiles more, less 'panic/anxiety/ attacks';\n also given morphine 1 mg IV overnight in single doses for pt's comfort;\n PERLA; smaller in diameter at times depending on how recent pt received needed meds;\n\nc-v:\n; NSR, no ectopy; except one isolated episode 5 beat salvo late last eve, posted in pt's blue med book;\n bil arm swelling seems to be decreasing, likely d/t therapeutic effects of STENT;\n\nresp:\npt w/ hx rt pneumonectomy, therefore any breath sounds auscultated on right are referred from left; left lung sounds coarse; clear abit with suctioning; pt occasionally c/o difficulty breathing; O2 sats good, resp rate good; ?--anxiety component, as stated pt suctioned at that time, lung sounds did improve abit;\n\ng-i:\nno stool this night; did have very soft/loose/thick liquid stool last night, would recommend considering Senna instead of Colace;\n receiving tube feeds w/out issue this night; FS's WNL's;\n\nskin:\n decube care 8a-8p; drssg c/d/i; using duoderm gel in cavity;\n\naccess:\nboth ports patent, red port flushes earsier than blue; one port clotted abit yesterday, likely the blue port; needs heparin flush at least q 8 hrs;\n\nPLAN: attempt to assist pt to return to vent/trach settings as prior to hospital course;\n\nSafety issues re pt.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 1463150, "text": "MICU NPN 1900-0700\n\nNo major events overnoc. Hct did not bumped adequately after unit transfused this afternoon. No s/s of active bleeding noted. Team aware.\n\nNeuro: Pt dozing on and off throughout the night. Pleasant and cooperative with all care. MAE. C/o of pain in abdomen at start of shift which was treated with morphine. No further c/o pain throughout the night. Morphine given this am for c/o of SOB. Pt is oriented x 3. Pt received standing dose haldol only.\n\nREsp: Remains on ACx10(rr 14-20)/500/40%/5peep. Sxned for thick yellow secretions. Pt given per RT. Occasional c/o of SOB which are resolved with sxning, MDIs, and this am Morphine. LS diminished on RT (s/p rt pneumanectomy), and coarse on left.\n\nCV: hemodynamically stable. HR, SB-NSR 55-83 with occasional PVCs. BP 85-139/76-55. HCt 29.8 this am. Will need to repeat Hct @ 8am. QTC .29. ? if pt will go to IR in the future to f/u with CT which showed a patent but compressed SVC possible cause of SVC syndrome. Pt's bilateral upper extremites are swollen.\n\nGI: TF restarted. Promote with fiber ordered with goal rate of 60cc/hr. Currently pt is tolerating 30cc/hr with minimal residuals. No BM this shift, +flatus. Bowel regime PRNs added this am by MD.\n\nGU: u/o 15-60cc/hr. BUN/CR wnl. Pt is currently negative 1285cc length of stay.\n\nSkin: multiple skin creams ordered. Dressing on remains intact.\n\nDispo: Remain in MICU. Full Code\n" }, { "category": "Nursing/other", "chartdate": "2179-02-03 00:00:00.000", "description": "Report", "row_id": 1463151, "text": "MICU nursing progress note 7A-7P\nPt to have MRI of SCV per request from IR. Pt to be sedated on propofol gtt for MRI, MRI checklist done by HO.\n\nNeuro - , oriented. Using call light or banging on siderails for attention. C/O back pain, \"pain all over\" x 2, medicated with MSO4 2 mg x 2 with relief. Also c/o SOB, Sx with resolution. Anxious at times, haldol ATC. No benzos per rehab as pt got increasingly agitated/confused on them. Propofol gtt for MRI. MAE, assists with turns.\n\nResp - Recieved on AC 500 x 10, +5, 40%. CPAP 18 + 5 for ~ 2 hrs until pt fatigued, placed back on AC mode where he will stay while sedated for MRI. Lungs diminished R side, Left is coarse. Sx frequently this AM for mod/copious thick yellow secretions which have lessened this afternoon. Sats 98-100%. RR 14-30, increasing to 40s when anxious.\n\nCV - BP 116->174/41-87, higher when anxious. SB/NSR, occ PVCs. Repeat Hct 31. Will recheck in AM. No S/S bleeding. INR 2.8 (pt was on coumadin for Afib) Stool OB (-). Bil upper extremity edema from SVC syndrome, will have MRI to further evaluate for ? stenting in IR.\n\nGI - Abd soft, +BS. Small soft stool x 1. TF advsanced 40cc/hr, off now for MRI and ? IR. Insulin (glargine) held for 84 this AM. Will start at half dose when FS increasing.\n\nGU - UOP 30-70cc/hr via foley.\n\nSkin - Multiple superficial areas on arms, ? old skin tears. Most are OTA. Dsg changed left arm. dsg changed on as ordered, on air bed. Pt on vitamin regime for nutrition.\n\nSocial - Wife will be in later today.\n\nPlan - MRI, propofol gtt for sedation. No benzos. ? stenting SVC in IR today or tomorrow. Wean from vent as tolerated. Back to when SVC stented, if no intervention, pt is ready to return to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-06 00:00:00.000", "description": "Report", "row_id": 1463165, "text": "Nursing Progress Note.\n\nRESP: Pt received on AC-10-40-500-8 c nl sats, breathing c set rate c nl resp effort. Small to moderate amounts of thick, off-white sec per 8# Portex trach today. LS vary between grossly coarse on L side to clear s/p successful sxn'ing. AM RSBI value of 123 noted. Pt is now on his 3rd Passe Muir valve \"trail\" c 15 of PS and 40% FiO2 and able to this setting for approx 30 min on first two attempts before c/o dyspnea/SOB. Pt coached to take deep breaths and med c anti-anxiety meds to assist c of Passe Muir valve trails. Will return pt to AC mode when before pts dyspnea is too pronounced.\n\nMS: The pt is pleasant/cooperative/MAE appearing fatigued @ times. With Passe Muir valve in place pt is able to consistently follow commands and articulate needs. times two c pt confused about date and place @ times, pt re-oriented to person/place/time to assist c nl cognition. Pt OOB c assist times two (for supervision primarily) for three hours today c good wt bearing in/out of bed. Pt returned to chair 30 min ago and will keep pt in chair as by pt. Pt c/o generalized body pain rated this AM and med c 1 mg IVP Morphine Sulfate times three today c good transitory affect noted. Morphine Sulfate also assists c pt self report of anxiety.\n\nCV: Hemodynamically stable and afebrile today. NSR c occ/rare PVC's and PAC's noted. UE edema cont to improve per wife assessment. As noted above pt now in BS chair for second time today and will keep in chair as c good wt bearing noted c transfer in/out of bed noted. Estimated QTi of .402 remains stable and therefore 14:00 2mg Haldol dose admin as scheduled.-\n\nGI: Full strength Promote c Fiber TF's rate adv from 40ml/hr to 60ml/hr today c low residuals per PEG. Will cont to adv rate as to target rate of 85mlhr per Nutrition rec note. Pt med c PRN Senna this AM and subsequently passed a medium sized soft stool this AM which was trace guaic positive. Abd is soft, NT and ND. Pt denies nausea, dyspepsia or other GI symptoms when asked.\n\nGU: Pt c borderline adequate hourly urinary output today. The pt is currently net positive 400ml input today but is net output 3.0 liters since admit. Urine is yellow in coloration c sm clots noted.\n\nCOAG: AM INR value of 1.9 noted, pt med c 5mg Warfarin per PEG @ 11:30 and will leave 20:00 7.5mg dose unchanged.\n\nDERM: Eggcrate cushion provided to pt for chair sitting. Please see CareVue for skin care data.\n\nSOC: Wife currently visiting pt @ BS and kept up-to-date c POC/pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-06 00:00:00.000", "description": "Report", "row_id": 1463166, "text": "Respiratory Care:\nPt. had 3 trials of PMV while on the vent, each for about 1/2 hour to 45 min. each time the event that precipitated returning to the vent was SOB with difficulty catching his breath. Otherwise he was fairly confortable while on CMV... 's given x 3 with Flovent @ 08:00.O2 Sat. = ~100%. See CareVue for details.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-07 00:00:00.000", "description": "Report", "row_id": 1463167, "text": "Resp Care: pt continues and on ventilatory support with a/c, no vent changes overnoc mainatining spo2 96%; bs coarse, sxn thick white secretions, rx with albuterol/atrovent as ordered, rsbi 101, will cont slow wean as .\n" }, { "category": "Nursing/other", "chartdate": "2179-02-07 00:00:00.000", "description": "Report", "row_id": 1463168, "text": "P-MICU NPN 7p-7a\nEvents overnight: Receiving Morphine for c/o back pain with good effect.\n\nResp: No vent changes made overnight. Remains and vented on A/C 40%/500/x10 with 8peep SRR 3-8. No ABG obtained this am. RSBI 125. LS coarse, on left, clearing with suctioning. Suctioned multiple times for thick white secretions. 02 Sats have remained in the upper 90's.\n\nNeuro: and oriented, pleasant and cooperative. Pt initially asleep, requesting Morphine for comfort r/t back pain. Received 2mg initially, with good effect. He received an additional 1mg dose times two. At times the pt woke quickly, calling RN, stating he couldn't breathe. His 02Sats at this time were in the high 90's, RR was slightly increased and pt had some secretions, that were cleared. He seemed to wake suddenly and startle, calling for the RN quickly. Recieved a little Morphine times 2, because he was also experiencing back discomfort at this time. For the most part pt slept fairly well all night, resting comfortably for a good part of the shift, settling quickly.\n\nCV: throughout night. BP 110's-130's. HR 60's-80's SR, no ectopy noted.\n\nEndo: FS 106/120. Received no SS coverage.\n\nGI: +BS, no stool this shift. TF's increased to goal rate of 85cc/hr. Minimal residuals noted.\n\nGU: U/O 30-40cc/hr.\n\nSocial: No contact from family this shift.\n\nSkin: Stage 3-4 , w->d packing applied. No smell noted, minimal drainage.\n\nID: Tmax 99.2po.\n\nLines: Difficulty flushing PICC, clamped removed and extension applies with good effect.\n\nHeme: No obvious S/SX of bleeding. Hct this am 29.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-04 00:00:00.000", "description": "Report", "row_id": 1463158, "text": "MICU nursing progress note 7A-7P\nPt went to IR this afternoon for stent to SVC, also had PICC placed in right upper arm. procedure well on propofol gtt and 150mcg fentanyl. Right groin cath site D&I, +PP. . Pt continues sedated on propofol gtt 55mcg/k/min for safety to keep right leg straight. Wife at bedside.\n\nNeuro - Pt anxious this AM. Frequently on call light, stating \"I can't breathe\" although Sats 99-100%, RR 14, not in any distress. Frequent discussions with pt re:coping, procedure. Pt very anxious about trip too IR. MSO4 x 2 for \"all over pain\". propofol gtt started to sedate pt without desired effect. Pt found standing at end of bed disconnected from vent. Assisted BTB with staff, pt increasingly agitated. HO called. Haldol 2 mg, increased dose propofol gtt, bedside sitter. Pt went to IR shortly after incident on propofol gtt and has remained on it for safety. Currently sedated, easily arouseable. Wife at bedside.\n\nResp - , AC 500 x 10, +8, 40%. Sats high 90s. Sx this AM frequently for thick yellow secretions. Lungs diminished right, coarse on left. RR 14-28.\n\nCV - BP 110-151/54-75. SB/NSR 48-80. Occ PACs. Heparin gtt prior to IR per IR request. Heparin off before pt went to IR and will remain off. QTc .442. Right groin checks q 30\" x 2 hrs, done @ 1900. HOB<20 until 1900.\n\nGI - ABd soft, +BS. Inc small loose stool. TF off for IR, may resart when HOB>30. Insulin held while NPO and <100.\n\nGU - UOP adequate. Pt is 1L neg so far today.\n\nSkin - dsg done x 2, no S/S infection. Pt on air-bed.\n\nSocial - Wife at bedside, all questions answered.\n\nPlan - Wean off propofol gtt. Sitter at bedside for safety. Pt to go to rehab () tomorrow. Wound care.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-05 00:00:00.000", "description": "Report", "row_id": 1463159, "text": "resp care\nPt remained on a/c 500x10 40%5peep all night with 8-15 breaths over the vent. BS coarse bil. Suct for creamy yellow sput. alb/atr/flovent given as ordered. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-08 00:00:00.000", "description": "Report", "row_id": 1463173, "text": "Nursing Progress/Transfer Note.\n\nRESP: Pt received respirating comfortably on MV settings of AC-10-40-500-8 c nl sats, RR, and resp effort. LS remain coarse on L side c mild clearing s/p sxn'ing for sm amounts of thick off-white sec. Passe Muir valve placed today and for approx 45min before c/o SOB and being returned to resting AC mode.\n\nCV: Hemodynamically stable and afebrile. NSR/sinus bradycardia c occ PAC's and rare PVC's. Adequate hourly UO.\n\nMS: times three when placed on Passe Muir valve. Pt is purposeful and consistently follows commands. MAE, pleasant/cooperative appearing mildly fatigue c little activity. Pt med c 2mg IVP Morphine Sulfate Q2 hrs for c/o /pressure ulcer pain c fair/transistory refief, team currently discussing increasing Duragesic patch dosing. Morphine sulfate dosing also assisted or minimized pts anxiety.\n\nGI: Pt cont to full strength Promote c Fiber @ target rate of 85ml/hr via PEG c low residuals evident. Pt passed large stool o/n. Pt denies nausea, abd fullness or dyspepsia.\n\nDERM: pressure ulcer dsg changed. Wound was cleaned c NS/sterile gauze f/b the application of Duoderm Gel/DSD. UE swelling cont to slowly improve.\n\nSOC: Wife visited pt today @ BS and kept up-to-date c POC/pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place. D/C referral and Page 2 completed and placed in pts chart for transfer back to . Wife aware of transfer and transferred the pts personal property to this facility just before transfer.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-07 00:00:00.000", "description": "Report", "row_id": 1463169, "text": "Nursing Progress Note.\n\nRESP: Pt received resting comfortably on AC-10-40-500-8 c nl sats, RR and resp effort. LS generally coarse today c some clearing s/p sxn'ing for small amounts of creamy, off-white sec. Pt approx one hour c Passe Muir valve in place this AM before c/o dyspnea, pt returned to resting AC mode. Pt currently has PMV back in place s c/o dyspnea @ this time. Pt able to speak in full sentences c good articulation c PMV in place. AM RSBI value of 101 noted. Pt c several episodes of dyspnea while on AC mode today, pt responded to verbal re-assurance and PRN 1mg IVP Morphine Sulfate times three today.\n\nCV: Hemodynamically stable and afebrile. NSR c occ PAC's and infreq PVC's. +1 Generalized anasarca slowly improving. RUE AC PICC in place c good blood return noted from both lumens. The pt is currently net positive one liter input today but is net output 1.8 liters since admit.\n\nMS: Pt more and oriented today c less mild confusion when compared to . The pt remains pleasant, cooperative, appreciative, MAE and in NAD. Pt cont to c/o anxiety and wound pain, responding well transitorily to low dose IVP 1mg Morphine Sulfate Q2-3 hrs. Pt freq re-oriented to person, time and place to assist c nl cognition.\n\nGI: Pt cont to full strength Promote c FIber tube feeds @ target rate of 85ml/hr via PEG c low residuals noted. Abd is soft, NT, ND.\n\nDERM: Please see CareVue for skin care data.\n\nSOC: Wife expected to visit pt shortly. No other calls/visitors received thus far today. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Page one D/C plan begun today. Univ isolation precautions in place.\n" }, { "category": "Nursing/other", "chartdate": "2179-02-07 00:00:00.000", "description": "Report", "row_id": 1463170, "text": "Respiratory Care\nPt on PSM for three separate trials today, lasting appro. 1 hr in length before becoming tired and requesting to be returned to the vent. Remains vented on A/C as noted on carevue. Plan to increase time on PSM.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-02-08 00:00:00.000", "description": "Report", "row_id": 1463171, "text": "Resp Care: Pt continues and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 97%; bs coarse, sxn thick white secretions, rx with as ordered, rsbi 114, will cont slow wean as .\n" }, { "category": "Nursing/other", "chartdate": "2179-02-08 00:00:00.000", "description": "Report", "row_id": 1463172, "text": "P-MICU NPN 7p-7a\nEvents overnight: Non symptomatic SVT, with HR into the 120's-130's, breaking without interventions.\n\nCV: Pt had been SB with occasional APC's noted on alarm review. Shortly after 12am, pt noted to have elevated HR into the 120's, with multiple APC's. Team aware and EKG obtained. While EKG was being obtained, pt broke spontaneously, without any interventions being taken. Pt was sleeping prior to episode and only awoke when EKG was being performed. BP was stable throughout episode. No meds were required. QTC this shrift normal: 0.39\n\nResp: Remains intubated and vented. No changes made this shift. Suctioned Q1-2hr for thick white secretions.\n\nNeuro: Appeared more anxious tonight. Requesting Morphine.\n\nSocial: No family contact this shift.\n\nSkin: Remains on kinair bed for promotion of skin healing. Sacral dressing completed, without noticible changes noted.\n\nLines: DL PICC line flushing without difficulties.\n\n\nGI: Minimal residuals, tolerating goal TF, promote with fiber at 85cc/hr.\n\nGU: U/O adequate, averaging 40-80cc/hr.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2185-03-16 00:00:00.000", "description": "O L-SPINE (AP & LAT) IN O.R.", "row_id": 822167, "text": " 9:40 PM\n L-SPINE (AP & LAT) IN O.R.; L-SPINE (AP & LAT) IN O.R. Clip # \n LUMBAR SP,SINGLE FILM IN O.R.\n Reason: CHECK FOR HARDWAREPLACEMENT\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Back pain, laminectomy with hardware placement.\n\n 8 intraoperative films taken in sequence demonstrate placement of orthopedic\n hardware with screws placed at L3-4 and T12 and L1 with subsequent rod\n placement stabilizing the surgical procedure.\n\n CONCLUSION: Sequential placement of orthopedic hardware as described above.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 822039, "text": " 4:47 PM\n L-SPINE (AP & LAT); T-SPINE Clip # \n Reason: trauma eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with\n REASON FOR THIS EXAMINATION:\n trauma eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n T AND L SPINE, FOUR VIEWS: There is normal alignment of the thoracic spine\n with preservation of vertebral and disc space height. No fractures are\n identified. The alignment is unremarkable.\n\n There is an anterior wedge compression fracture of the L1 vertebral body.\n There is also minimal retrolisthesis of L1 on L2. The rest of the vertebral\n bodies are unremarkable. The hips and SI joints are unremarkable. Note is made\n of IV contrast dye within the renal collecting systems.\n\n IMPRESSION: Anterior wedge compression fracture of the L1 vertebra with loss\n of vertebral body height and possible retropulsion of vertebral body\n fragments. Minimal retrolisthesis of L1 on L2. The canal is narrowed at this\n point as seen on subsequent CT scan.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 822557, "text": " 7:53 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess for atelectasis\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with\n\n REASON FOR THIS EXAMINATION:\n please assess for atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess atelectasis.\n\n TECHNIQUE: PA and lateral views of the chest were obtained, compared with the\n prior study performed two days ago.\n\n FINDINGS: Spinal fusion hardware is unchanged in orientation, without\n evidence of hardware failure. The region of linear atelectasis at the left\n lung base has resolved. There are no regions of focal pulmonary opacities,\n pleural effusions, or evidence of pneumothorax. The cardiomediastinal\n silhouette is within normal limits.\n\n IMPRESSION: Resolution of left lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 822025, "text": " 3:02 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: trauma eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n trauma eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21 y/o post 40 foot fall and foot pain.\n\n 3 VIEWS OF THE LEFT FOOT:\n\n There are no fractures or dislocations. The joint spaces are preserved. There\n are no focal intra-osseous lesions, and there is normal mineralization. The\n soft tissues are unremarkable.\n\n IMPRESSION: No fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 822022, "text": " 2:36 PM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: TRAUMA, FALL FROM ROOF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with burst fx of L1\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TKE TUE 3:57 PM\n burst fx of L1 slight compromise of spinal canal disc bulge l4-5\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n CLINICAL INFORMATION: Burst fracture of L1.\n\n NONCONTRAST CT OF THE LUMBAR SPINE WITH MULTIPLANAR REFORMATTED IMAGES\n\n FINDINGS: There is a fracture of the body of L1 with loss of height anteriorly\n and relative preservation of height posteriorly. There is slight retropulsion\n of bone fragments into the spinal canal. There is a distraction fracture of\n the pedicle of L1 on the right side and there are posterior element fractures\n with slight displacement of the left lamina into the spinal canal on the left\n side. There is no evidence of fracture of the remaining lumbar vertebrae.\n There is a transitional vertebra at the lumbosacral junction with a\n pseudapophysis on the left side. There is generalized disc bulging at L4-5\n without evidence of a focal disc protrusion.\n\n IMPRESSION: Burst fracture of L1.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 822023, "text": " 2:36 PM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: TRAUMA, FALL FROM ROOF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with burst fx of L1\n REASON FOR THIS EXAMINATION:\n eval for fracture\n CONTRAINDICATIONS for IV CONTRAST:\n N\n ______________________________________________________________________________\n WET READ: TKE TUE 3:48 PM\n facet irregularities at t2-3,t8-9,t9-10,t10-11 and t11-12 probably\n degenerative but r/o facet fx's\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n CLINICAL INFORMATION: Fall from roof burst fracture or L1.\n\n NONCONTRAST CT OF THE THORACIC SPINE WITH MULTIPLANAR REFORMATTED IMAGES\n\n FINDINGS: The fracture of L1 will be described under the lumbar spine study.\n There is some irregularity in the region of the facet joints at T2-T3, T8-T9,\n T9- T10, T10-T11, and T11-T12. It is not clear if this is degenerative in\n nature or if there could be a minimal facet fractures in this region. The fact\n that they are quite symmetric and they are present at multiple levels suggests\n that they are degenerative in nature and perhaps represent some ligamentous\n calcification. There is no definite evidence of compression fracture of a\n thoracic vertebral body.\n\n IMPRESSION: Some irregularity in the region of the facet joints posteriorly at\n multiple levels as described. The findings are most likely degenerative but\n see above discussion. A definite fracture anteriorly is not identified.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 822088, "text": " 8:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: question cerebellar bleed\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with L 1 burst fracture s/p fall from roof\n REASON FOR THIS EXAMINATION:\n question cerebellar bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT SCAN:\n\n HISTORY: Previous CT scan raised the question of a right cerebellar\n hemorrhage.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n FINDINGS: There is no sign of a cerebellar hemorrhage or other site for\n similar pathology within the brain parenchyma. There is no hydrocephalus or\n shift of normally midline structures, or observable major vascular territorial\n infarction.\n\n There is considerable prominence of the posterior superior nasopharyngeal soft\n tissues which could well be enlarged adenoids in a patient of this age.\n\n CONCLUSION: No verification of intracranial hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 822019, "text": " 1:56 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: TRAUMA, FALL FROM ROOF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n trauma eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TKE TUE 3:32 PM\n negative\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Trauma fall from roof.\n\n NONCONTRAST CT OF THE CERVICAL SPINE WITH MULTIPLANAR REFORMATTED IMAGES\n\n FINDINGS: There is no evidence of fracture or dislocation. The nasopharyngeal\n tissues are somewhat prominent consistent with prominent lymphoid tissue in\n this young patient.\n\n IMPRESSION: No evidence of fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 822020, "text": " 1:57 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: TRAUMA, FALL FROM ROOF.\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n trauma eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22 year old post 40-foot fall.\n\n TECHNIQUE: CT angiogram of the aorta. Contiguous axial images from the lung\n apices through the pubic symphysis were obtained after administration of 150\n cc of Optiray. Optiray was used due to need for fast bolus technique.\n\n CT OF THE CHEST WITH IV CONTRAST: Soft-tissue windows reveal no axillary,\n mediastinal, or hilar lymphadenopathy. The heart and pericardium are normal.\n No pleural effusions. Lung window images reveal several patchy multifocal\n bilateral areas of ground glass opacification, some with a more nodular\n appearance. There is no focal consolidation or pneumothorax.\n\n Bone windows reveal no suspicious lytic or blastic lesions within the thorax.\n There is irregular lucency in the T12 vertebral body possibly representing a\n fracture.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, adrenals, pancreas,\n gallbladder, intraabdominal large and small bowel are all normal in\n appearance. The kidneys have tiny hypodense cysts bilaterally, but are\n otherwise normal. There is no free fluid or free air in the abdomen. No\n bowel wall thickening is seen. There is a paucity of mesenteric fat within\n the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, distal ureters,\n bladder, and prostate are normal. No extravasation of contrast is seen from\n the bladder. A Foley with associated air is seen in the bladder. There is no\n free fluid or lymphadenopathy in the pelvis.\n\n Bone windows reveal a burst-type fracture of the L1 vertebral body including\n the lamina on the left and the left pedicle. There appear to be a few small\n retropulsed fragments without obvious impingement upon the cord. In addition,\n there is lucency of the left L5 transverse process likely representing a\n fracture. The sacrum, bilateral acetabula, and pelvis show no other\n fractures.\n\n CT ANGIOGRAM OF THE AORTA: The aorta is normal in caliber and contour\n throughout its course from the aortic root through the aortic bifurcation.\n There is no extravasation of contrast, dissection, or aneurysm. Normal\n contrast enhancement is seen within the celiac, superior mesenteric, infmes,\n (Over)\n\n 1:57 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: TRAUMA, FALL FROM ROOF.\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and renal arteries with no evidence of extravasation. The iliac arteries are\n normal in appearance.\n\n IMPRESSION:\n\n 1) Normal CT angiogram with no evidence of dissection or extravasation of\n contrast.\n\n 2) Patchy multifocal bilateral ground glass opacities in the lungs which are\n nonspecific. These could represent aspiration, contusion, or atelectasis,\n though they are not typical for contusions.\n\n 3) Burst fracture of the L1 vertebral body and lamina/pedicle with a few small\n retropulsed fragments. No impingement upon the cord. Possible fracture of\n T12 and L5 left lateral process. A dedicated thoracolumbar CT is recommended\n for better evaluation of the spine.\n\n 4) Normal CT of the abdomen and pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-22 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 822630, "text": " 3:12 PM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: 21 yr old male s/p 0 ft with right wrist pain pleasse\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with\n REASON FOR THIS EXAMINATION:\n 21 yr old male s/p 0 ft with right wrist pain pleasse assess for scaphoid\n fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall with wrist pain.\n\n RIGHT WRIST, AP, LATERAL & OBLIQUE VIEWS:\n\n No fracture or dislocation detected. The joint spaces are preserved. No focal\n bony lesion is identified.\n\n If symptoms persist, repeat films after an interval could be obtained.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "P TRAUMA #2 (AP CXR & PELVIS PORT) PORT", "row_id": 822017, "text": " 1:55 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) PORT Clip # \n Reason: trauma eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n trauma eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21 y/o with trauma, fall of feet.\n\n SINGLE PORTABLE FRONTAL CHEST & PELVIS:\n\n The cardiac contour is normal. The mediastinumis unremarkable for technique.\n The lungs are clear with no effusion, consolidation, or pneumothorax. There is\n no pneumomediastinum. The pulmonary vasculature is normal. No fractures are\n identified.\n\n SINGLE VIEW OF THE PELVIS reveals no fractures or dislocations. A metallic\n chain overlies the right acetabulum, somewhat limiting evaluation of this\n area. No focal intra-osseous lesions are seen.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 822018, "text": " 1:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: TRAUMA, FALL FROM ROOF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n trauma eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TKE TUE 2:34 PM\n possible right cerebellar hematoma see arrow\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n CLINICAL INDICATION: Trauma.\n\n CONCONTRAST HEAD CT\n\n FINDINGS: On image 8 there is a questionable area of increased density in the\n region of the right cerebellar hemisphere-middle peduncle juntion. This could\n be artifact. It could represent a focus of intraparenchymal hemorrhage.\n Otherwise there is no definite evidence of mass effect or hemorhage.\n Ventricles and sulci are not remarkable. The supratentorial and white\n matter is not unusual. There is no dispacement of normally midline structures.\n The visualized paranasal sinuses are clear.\n\n IMPRESSION: Possible right cerebellar hemorrhage see above discussion.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-16 00:00:00.000", "description": "MR L SPINE SCAN", "row_id": 822062, "text": " 1:48 AM\n MR L SPINE SCAN Clip # \n Reason: trauma eval with stir images per neurosurg\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with 45 ft fall\n\n REASON FOR THIS EXAMINATION:\n trauma eval with stir images per neurosurg\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE LUMBAR SPINE DATED .\n\n INDICATION: 21 year-old man with 45 foot fall. Evalute fracture.\n\n TECHNIQUE: Sagittal T1, T2, and STIR imaging of the lumbar spine was obtained\n in addition to axial T1 and T2 weighted images from T12 through the upper\n sacrum. No IV contrast was administered.\n\n COMPARISON: CT scan dated .\n\n FINDINGS: As described in the patient's recent CT scan, there is \n fracture of the L1 vertebral body. There is retropulsion of the fracture\n fragments with narrowing of the central canal. The degree of retropulsion is\n stable since the CT scan. There is no compression of the cauda equina. There\n is no evidence of disk herniation, though the L1-2 disk does appear disrupted.\n No intraspinal fluid collections are identified.\n\n The remainder of the alignment in the lumbar spine is normal. There is a disk\n protrusion with disk desiccation at L4-5. This disk protrusion results in no\n impingement on the central canal or neural foramina bilaterally. It's age is\n indeterminate.\n\n IMPRESSION: No interval change in L1 vertebral body burst fracture compared\n with recent CT. No additional fracture is identfied. L4-5 disk protrusion\n without impingement, age indeterminate.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-16 00:00:00.000", "description": "MR THORACIC SPINE", "row_id": 822063, "text": " 1:49 AM\n MR THORACIC SPINE Clip # \n Reason: stir images per neurosurg\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with 45 ft fall\n\n REASON FOR THIS EXAMINATION:\n stir images per neurosurg\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21 y/o man with known L1 fracture status 45ft fall. Assess for\n additional injury.\n\n TECHNIQUE: Sagittal T1, T2 and STIR imaging of the thoracic spine was\n performed without IV contrast.\n\n FINDINGS: There is normal alignment throughout the visualized cervical and\n thoracic spine. There is perservation of the vertebral body heights and disc\n space heights. No acute fractures are identified and there is no high signal\n in the STIR imaging to suggest bony edema. The signal in the spinal cord is\n normal. No fluid collections are identified within the central canal.\n Lobulated soft tissue in the anterior mediastinum presumably relates to the\n sinus in this young patient.\n\n IMPRESSION:\n\n Normal MRI appearance of the thoracic spine.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-21 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 822498, "text": " 9:14 AM\n L-SPINE (AP & LAT) Clip # \n Reason: Please assess for post-op instrumentation - please perform f\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Post-op from L1 burst fracture w/ T11-L3 fusion\n REASON FOR THIS EXAMINATION:\n Please assess for post-op instrumentation - please perform films standing and\n cover lower thoracic and lumber region\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop film. The patient has L1 burst fracture and is s/p fusion\n of T11 through L3.\n\n FINDINGS: Standing AP & lateral views of the lumbar spine were performed (4\n films total). There is a compression fracture of the L1 vertebral body with\n less than 20% loss of its height. Interpedicular screws traverse the T11, T12,\n L2 and L3 vertebral bodies. There has been a laminectomy at L1 and L2. The\n posterior elements of L3 cannot be seen due to overlying hardware. There is\n anatomic alignment of the lumbar spine. Bony packing material is seen along\n the lateral aspect of the hardware. Skin staples are still present. There are\n minor degenerative changes at the L5/S1 levels.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 822392, "text": " 12:22 PM\n CHEST (PA & LAT) Clip # \n Reason: 21 yr old male s/p T11_l3 fusion spiked at temp to 102 pleas\n Admitting Diagnosis: S/P 45 FOOT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with\n REASON FOR THIS EXAMINATION:\n 21 yr old male s/p T11_l3 fusion spiked at temp to 102 please assess for\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS:\n\n INDICATION: 21 y/o man with thoracic spine fusion, fever.\n\n COMMENT: PA & lateral radiographs of the chest are reviewed. No previous study\n is available for comparison.\n\n The patient is s/p thoracic spine fusion with multiple surgical staples. There\n is small bilateral pleural effusions. Patchy atelectasis is seen at the lung\n bases. The lungs are clear otherwise. The heart and mediastinum are within\n normal limits.\n\n IMPRESSION: No evidence for pneumonia.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-16 00:00:00.000", "description": "Report", "row_id": 1433362, "text": "TSICU Nursing Admit Note\nPt is 21y.o. male who fell 45feet off a roof while at work. No LOC at the scene, GCS of 15, c/0 severe back pain. CT scan showed L1 burst fx, L1 TP fx, and ? cerebellar hematoma. To ICU for serial neuro checks. Has been neurologically intact since admission. Will repeat CT scan in am to evaluate hematoma. Still needs MRI. Awaiting slot to open up in MRI. No PMH/PSH per pt. NKDA.\n\nReview of Sytems:\n\nNeuro...A&Ox3, calm, cooperative, following commands. Pupils 3mm bilaterally and reactive. Sensation intact throughout. Moves BUE well and with equal strength. Grips equal. Moves BLE well, but when asked to push against hands, LLE weaker. Pt c/o pain here. X-rays done in ER, unsure of results yet. Main c/o pain is in lower back area. MSO4 IVP given in 2mg increments with moderate effect seen. Remains strict log roll. Hard field collar changed to J.\n\nCV...NSR with no ectopy. HR 70-80's. BP stable. Palpable peripheral pulses. LR at 100cc/hr.\n\nRESP...On RA with sats >96%. Lung fields clear to auscultation.\n\nGI...Abd softly distended with hypoactive BS. Emesis x1 in ER. None since here. Denies nausea. Pepcid started.\n\nGU...Minimal urine output since arrival to unit. Notified Dr. . 500cc LR bolus given with only small pick up seen as of yet. Lytes pending.\n\nHEME...Labs still pending.\n\nID...Tmax 100.0. No abx coverage.\n\nSKIN....Small lacs to both hands. Coccyx mildly reddened.\n\nSOCIAL...Multiple family members present while in ER. Contact phone numbers left. No contact with family since in unit. Pt states he lives with friends. as a roofer.\n\nPLAN....MRI. CT scant this am to evaluate ? hematoma. Serial neuro checks. Manage pain.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-17 00:00:00.000", "description": "Report", "row_id": 1433363, "text": " \"B\": Nsg Progress Note:\n\nCVS: Skin warm and dry. Pulses palpable. Afebrile. HR60's when intubated on Propofol drip. After extubation has been in ST 110-124.\nSBP110-144. Aline bp higher than cuff. IV NS+20 Meq KCL at 100cc/h.\nPt on PCA DIlaudid, using it appropriately most of the time. Given Ativan x3 for agitation. Kept restrained until pt fully oriented. Pt has to ask where he is and stated he thought he was in a music video. thrashing in bed at times.\n\nNeuro: MAE, good sensation and strength. Pupils+=. No deficits noted.\nC/o pain in back, dsg clean, dry and intact. Pain med with PCA with relief.\n\nResp: Weaned to RA, sats=100% , ABG good. Lung sounds clear.\n\nGU: U/o good.\n\nGI: Ice chips only during night.,+BS.\n\nSkin: Small abrasions noted on extremities, none open or draining.\n\nPlan: Back brace to be obtained today, then pt may sit up and transfer to floor.\n" } ]

[ { "category": "Radiology", "chartdate": "2157-03-02 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1226221, "text": " 10:04 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: please replace right femoral TLC with HD line. Please confir\n Admitting Diagnosis: PERITONITIS\n Contrast: OMNIPAQUE Amt: 35\n ********************************* CPT Codes ********************************\n * EXCH CENTRAL NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with needs HD\n REASON FOR THIS EXAMINATION:\n please replace right femoral TLC with HD line. Please confirm placement in\n iliac vein, as pt has tortuous vein.\n ______________________________________________________________________________\n FINAL REPORT\n REPLACEMENT OF RIGHT FEMORAL TRIPLE-LUMEN CENTRAL VENOUS CATHETER WITH\n HEMODIALYSIS CATHETER PLUS VIP PORT\n\n INDICATION: 47-year-old man in need of hemodialysis.\n\n OPERATORS: Drs. (fellow) and (attending\n physician). Dr. reviewed the images.\n\n CONTRAST: Sterile 30 mL Omnipaque 350.\n\n SEDATION: None.\n\n PROCEDURE AND FINDINGS: Consent was obtained after explaining the benefits,\n risks, and alternatives. Patient was placed supine on the imaging table in\n the interventional suite. Timeout was performed as per protocol.\n\n Initial scout fluoroscopic image demonstrated right femoral venous catheter\n tip projecting over the pelvis. A 0.035 wire was advanced through one of\n the ports, however, it could not be advanced much further into the IVC.\n Sterile contrast material was injected through another port to perform IVC\n gram, which demonstrated patent IVC. Old catheter tip was likely in a\n tributary/collateral vein. As it was difficult to negotiate the wire\n into the IVC, it was replaced with an angled stiff Glidewire, which was then\n successfully advanced into the upper IVC and eventually into the SVC. Old\n catheter was removed. Tract was dilated under fluoroscopy with a 12 French\n dilator. A new 12 French 20 cm hemodialysis catheter with VIP port was placed\n over the wire, which was then removed. A small amount of sterile contrast\n material was injected through one of the ports to confirm the position of its\n tip in the upper right common iliac artery. Ports were aspirated and flushed\n freely. Catheter was secured by 0 silk sutures. Site was appropriately\n dressed. Patient tolerated the procedure well and no immediate post-procedure\n complication was seen.\n\n IMPRESSION: Uncomplicated IVC gram and fluoroscopy-guided exchange of right\n femoral central venous catheter with a new 12 French 20-cm hemodialysis\n catheter with a VIP port with tip in the IVC. It is ready for use.\n (Over)\n\n 10:04 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: please replace right femoral TLC with HD line. Please confir\n Admitting Diagnosis: PERITONITIS\n Contrast: OMNIPAQUE Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2157-03-04 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1226533, "text": " 1:01 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: placement of tunneled HD line\n Admitting Diagnosis: PERITONITIS\n Contrast: OMNIPAQUE Amt: 5\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O TUNNELED W/O PORT *\n * -59 DISTINCT PROCEDURAL SERVICE FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with ESRD on PD. Need tunneled HD line.\n REASON FOR THIS EXAMINATION:\n placement of tunneled HD line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 47-year-old man with end-stage renal disease, on peritoneal\n dialysis. Needs tunneled HD line placement as well as power PICC placement.\n\n RADIOLOGISTS: Dr. , resident, Dr. , fellow, Dr. \n , attending. Dr. , the attending, was present during the\n entire procedure.\n\n ANESTHESIA: Anesthesia was provided with local 1% lidocaine along with 1%\n lidocaine mixed with epinephrine. Moderate sedation was provided by\n administering divided doses of fentanyl and Versed throughout the total in\n service of 115 minutes during which the patient's hemodynamic parameters were\n continuously monitored. Total of 150 mcg of fentanyl and 2 mg of Versed were\n used.\n\n PROCEDURE: After informed written consent was obtained outlining the risks\n and benefits of the procedure, the patient was brought to angiographic suite\n and placed on table in supine position. A timeout was performed per \n protocol. The patient's right and left neck along with right and left groin\n areas were prepped and draped in the usual sterile fashion.\n\n Ultrasound was used to initially evaluate the left internal jugular, which was\n patent proximally but appeared occluded distally. The proximal left internal\n jugular was able to be accessed via a micropuncture needle; however, no wire\n was able to be passed. 5 mL of contrast were used to see if contrast will\n flow through the internal jugular, but no contrast was seen flowing centrally.\n Micropuncture needle was then removed and pressure was held and attention was\n diverted to the left groin.\n\n At the left groin, the patent left common femoral was accessed via ultrasound\n guidance. A 21-gauge micropuncture needle was used to access the vein. This\n was exchanged for a 4-French sheath and over a nitinol wire. Attention was\n then diverted to creating the tunnel site. Site was anesthetized with\n lidocaine and 1% lidocaine with epinephrine. A double-lumen Power PICC was\n then tunneled through the tunnel site to the venopuncture site. The 4 French\n microcatheter sheath was exchanged for a pull-away sheath. The PICC was then\n (Over)\n\n 1:01 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: placement of tunneled HD line\n Admitting Diagnosis: PERITONITIS\n Contrast: OMNIPAQUE Amt: 5\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inserted through the pull-away sheath and advanced up the inferior vena cava.\n Initial images show that the PICC was curled just below the right atrium. A\n 0.018 guidewire was used to straighten the PICC into correct position. PICC\n was then seen in correct position terminating in the right atrium. The\n guidewire was removed. The venopuncture site was sutured using 2-0 Vicryl.\n The double-lumen Power PICC was aspirated and flushed and both lumens were\n functioning appropriately. The site was then cleaned and dressed with sterile\n dressings.\n\n Attention was then diverted to the right groin where the patient already had a\n right temporary femoral line with VIP port. This was left in place initially\n and a tunnel site was marked, which was anesthetized with 1% lidocaine with\n epinephrine as well as 1% lidocaine subcutaneously. A tunnel was then created\n and brought through the original venopuncture site. An angiodynamic 15.5 Fr x\n 55 cm duraflow catheter was tunneled. The right line was was then removed\n after a Amplatz wire was advanced into the IVC. A peel-away sheath was then\n inserted over the Amplatz wire. The Amplatz wire was removed and the tunneled\n angiodynamic line was inserted into the peel-away sheath. The peel-away\n sheath was then removed and the site was closed with a sterile dressing.\n\n Final fluoroscopic images showed the tunneled hemodialysis catheter within the\n right femoral ending in the right atrium as well as a 50 cm tunneled central\n double-lumen Power PICC from the left femoral access ending within the right\n atrium. The tunneled hemodialysis catheter was secured to the skin using 4-0\n Vicryl.\n\n FINDINGS: Venogram demonstrating occlusion of the left distal IJ and\n brachiocephalic stenosis.\n\n IMPRESSION:\n 1. Successful placement of left femoral tunneled Power PICC with the tip\n ending in the right atrium.\n 2. Conversion of existing right femoral line into a right femoral tunneled\n 15.5 French HD catheter with its tip also in the right atrium.\n\n\n" }, { "category": "ECG", "chartdate": "2157-03-01 00:00:00.000", "description": "Report", "row_id": 255455, "text": "Sinus rhythm. Similar findings to those described in tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2157-03-02 00:00:00.000", "description": "Report", "row_id": 255454, "text": "Sinus rhythm with first degree atrio-ventricular conduction delay. Right\nbundle-branch block. Left axis deviation. Left anterior fascicular block.\nCompared to the previous tracing of multiple abnormalities as\npreviously reported persist without diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2157-02-28 00:00:00.000", "description": "Report", "row_id": 255456, "text": "Sinus rhythm with prolonged A-V conduction. Complete right bundle-branch block\nwith left anterior fascicular block. Left axis deviation. Compared to the\nprevious tracing of no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2183-07-30 00:00:00.000", "description": "Report", "row_id": 1517958, "text": "Admission note\n86yo female pt with h/o PE/DVT on coumadin and diverticulosis /polyps/BRBPR in . Arrived from EW via ambualance @ 1900 after her Hct dropped from 28.4 to 25.8 rectal/LGI bleed in the setting of supratherapeutic INR of 3.8. She was referred to ED by her PCP after she and her visiting nurse noticed dark and bright red blood with clots during her bath.\nUpon admission, pt was alert/oriented, cooperative,VSS, afebrile. She denied CP/palps or dizziness. Her husband was at her side and served as her medical historian; pt is followed by behavioral neurology for dementia. Plan includes am EGD and colonoscopy.\n" }, { "category": "Nursing/other", "chartdate": "2183-07-30 00:00:00.000", "description": "Report", "row_id": 1517959, "text": "NPN 1900-0700\nFull code NKDA\n\nNeuro: Very pleasant, alert, oriented to self/place; memory deficit. On Namenda and Aricept. MAE. Afebrile.\n\nCV: AM Hct pending, stable @ 25.7 last noc. SR-SB with HR 49-70's, 1st degree AVB. SBP's 1teen's to 160. Denies CP/palps/dizziness. Continues to experience melena, some clots. No emesis. +PPP's b/l, neg extremity edema.\n\nResp: RRR in teens, sats 95-100% on RA. LSCTA b/l.\n\nGI: Soft mildly distended abd w/ +BS throughout. Nontender. Stooling q1-2h. Magnesium citrate 450ml x2, not yet clear. Due for EGD/colonoscopy today.\n\nGU: Patent foley draining clear light yellow urine @ >60cc/hr. Suprapubic reducible hernia\n\nSkin: CDI\n\nMusc/Skeletal: Kyphosis, osteoporosis. Ambulates minimally w/walker according to husband but @ bedside\n\nLines: PIV x2 L, patent.\n\nSocial: Husband, arrived with her last night, has a daughter whom was notified by . States that she also has a son. services\n\nPlan: Monitor and support hemodynamics\n NPO; Liter #2 of 2 IVF running\n Monitor stooling/clearing for colonoscopy\n Skin care\n Encourage t/c/db.\n Emotional support, reorient if necessary. Namenda due this am, in pt's Omnicell bin\n\n\n" }, { "category": "Radiology", "chartdate": "2183-08-05 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 974950, "text": " 1:37 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for malignancy\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with GI bleed, colonoscopy unable to eval past sigmoid,\n concerning for mass\n REASON FOR THIS EXAMINATION:\n please eval for malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITHOUT IV CONTRAST\n\n INDICATION: 86-year-old woman with GI bleed, colonoscopy unable to evaluate\n past-sigmoid, concerning for mass. Please evaluate for malignancy.\n\n COMPARISON: .\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet through the pubic symphysis with oral contrast. Coronal and\n sagittal images were obtained. IV access was not able to be obtained.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: In the imaged portion of the thorax,\n there is mild bibasilar dependent atelectasis. The heart and great vessels\n appear normal. There are vascular calcifications. The study is limited\n without IV contrast. The liver, kidneys, adrenals, spleen, and pancreas\n appear normal. There are extensive vascular calcifications. The stomach and\n small and large bowel are unremarkable. There is no retroperitoneal or\n mesenteric lymphadenopathy.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The rectum appears normal. There is\n severe sigmoid diverticulosis with wall thickening. There is no evidence for\n diverticulitis. There is no free air or free fluid seen in the pelvis. There\n is no pelvic or inguinal lymphadenopathy, although streak artifact from\n bilateral total hip replacements limit evaluation in this region. There is a\n right likely femoral hernia. There is a right buttock calcified granuloma.\n\n OSSEOUS STRUCTURES: There is no suspicious lytic or blastic lesion, there are\n degenerative changes and bilateral hip replacements.\n\n IMPRESSION:\n 1. Limited study demonstrating no evidence for GI mass; severe sigmoid\n diverticulosis with wall thickening without evidence for active inflammation.\n 2. Right likely femoral hernia.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-08-01 00:00:00.000", "description": "PICC W/O PORT", "row_id": 974410, "text": " 2:12 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Place a PICC or mid line. DO NOT USE RIGHT ARM\n Admitting Diagnosis: LOWER GI BLEED\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 GI bleed, needs IV access\n REASON FOR THIS EXAMINATION:\n Place a PICC or mid line. DO NOT USE RIGHT ARM\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE NAME: PICC line placement.\n\n INDICATION: 86-year-old woman with GI bleeding, needs IV access. The\n procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGISTS: Dr. performed the procedure, with Dr. , the\n attending radiologist supervising throughout the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the brachial vein\n was punctured under direct ultrasound guidance using a micropuncture set. Hard\n copies of ultrasound images were obtained before, and after establishing\n intravenous access. A peel-away sheath was then placed over a guidewire and a\n single lumen PICC line measuring 43 cm in length was then placed through the\n peel-away sheath with its tip positioned in the SVC under fluoroscopic\n guidance. The position of the catheter was confirmed by fluoroscopic spot\n film of the chest. The peel-away sheath and guidewire were then removed. The\n catheter was secured to the skin, flushed, and sterile dressing applied. The\n patient tolerated the procedure well. There were no immediate post-procedure\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopic-guided left single\n lumen PICC line placement by the left brachial venous approach. The final\n internal length is 43 cm, with the tip positioned in the SVC. The line is\n ready for use.\n\n\n\n" }, { "category": "ECG", "chartdate": "2183-07-29 00:00:00.000", "description": "Report", "row_id": 117721, "text": "Sinus bradycardia. Borderline first degree A-V block. Compared to tracing\nof anterolateral ST-T wave abnormalities have resolved.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2178-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582591, "text": "81 yr male admitted to OSH for tx of pna.?TTP vs. cancer per\n report. Platelet count 15, pt bleeding from upper palate and coughing\n up blood. Hct 29.7. Pt transferred to 11R from OSH. On floor pt satting\n 90-92% NRB. Pt being transferred to for hypoxia and ? need for\n plasmapheresis. Pt is full code; however, per report pt was DNR/DNI at\n OSH - code status to be clarified.\n" }, { "category": "Nursing", "chartdate": "2178-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582607, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was essentially normal. He\n was placed on levofloxacin for possible pneumonia, although there he\n did not have fevers. In addition, he was put on solumedrol 125mg IV\n (first day ). He began to develop ecchymoses and mild hemoptysis;\n CBC demonstrated marked thrombocytopenia with platelets falling from 93\n to 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound\n that did not show any evidence of cirrhosis. Hematology was consulted\n and became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2178-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582608, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Pt coughed out blood small amount clots several times, used yankeur\n sometimes to clear the mouth but he is unable to collect that in\n specimen container. unclear whether haemoptysis or bleeding from\n mouth,or hard palate .plt 15, crit 29. WBC 15 .afebrile. voided\n moderate amount urine. K 5.4\n Action:\n Cefipime 2gm stat given and started with regular dose,waiting for ID\n approval Rt femoral pheresis catheter inserted by Dr. \n and started with plasmapheresis by haematology team after the\n conscent . keyoxalate 30gm po given. IVF N/s 500c given for\n hydration.pt NPO\n .\n Response:\n Pt cooperative with the procedure. Vss. Afebrile. having bleeding from\n the pheresis cath site. Pt code status confirmed with pt as DNR/DNI .\n Plan:\n Continue with monitoring lytes, CBC /bleeding . f/u with haem team for\n pheresis.\n" }, { "category": "Nursing", "chartdate": "2178-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582609, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Pt coughed out blood small amount clots several times, used yankeur\n sometimes to clear the mouth but he is unable to collect that in\n specimen container. unclear whether haemoptysis or bleeding from\n mouth,or hard palate .plt 15, crit 28.2. WBC 23 .afebrile. voided\n moderate amount urine. K 5.2\n Action:\n Cefipime 2gm stat given and started with regular dose,waiting for ID\n approval Rt femoral pheresis catheter inserted by Dr. \n and started with plasmapheresis by haematology team after the\n conscent . keyoxalate 30gm po given. IVF N/s 500c given for\n hydration.pt NPO\n .\n Response:\n Pt cooperative with the procedure. Vss. Afebrile. having bleeding from\n the pheresis cath site. Pt code status confirmed with pt as DNR/DNI .\n Plan:\n Continue with monitoring lytes, CBC /bleeding . f/u with haem team for\n pheresis.\n" }, { "category": "Physician ", "chartdate": "2178-07-12 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 582601, "text": "Chief Complaint: hypoxic 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 81 y.o. man who presented to an outside hospital with dyspnea on\n minimal exertion, found to have right lung infiltrate, treated for PNA\n with levoquin and COPD flare with solumedrol, never febrile, initial\n WBC 9, plts 95K. Leukocytosis on steroids. Subsequently had plt drop\n <20K, developed bleeding form oropharynx, hemopytsis. Unable to\n quantify. Transferred to for ?TTP to the medical floor, found to\n have Sa02 ~92% on NRB and transferred to MICU given tenuous respiratory\n status.\n On further history obtained from patient's son/daughter and friend\n (whom he lives with) patient has had a chronic cough previously\n minimally productive for white and occasionally yellow tinged sputum.\n No prior hemoptysis before thrombocytopenia developed. Had significant\n weight loss (guessing 30#) over the winter while in . Upon\n return was seen at JP for cough, abnormal CXR prompting a CT chest\n on showing R hilar LAD, RML/RLL and LLL infiltrates. ?treated at\n that time for PNA albeit not clear what abx, restarted MDIs. Dyspnea\n continued to get progressively worse until SOB with minimal exertion\n (ambulating across the kitchen in the restaraunt below where he lives).\n Denies CP, LE edema, PND, F/C/S, N/V/D. Son notes he was treated for\n PNA ~ 1 year ago as well.\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n keppra\n simbastatin\n atenolol\n lisnopril\n solumedrol\n Past medical history:\n Family history:\n Social History:\n Pacemaker\n CEA\n COPD\n Seizure disorder of unclear etiology - last episode >2 years ago\n HTN\n Noncontributory\n Occupation: retired waterfront worker from \n Drugs: None\n Tobacco: 1 ppd x 70 yrs; none since 1 week\n Alcohol: Remote use\n Other: Wife died of lung CA, mets to CNS\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: dried blood in oropharynx, old in appearance\n Nutritional Support: NPO\n Respiratory: Cough\n Heme / Lymph: Anemia, Coagulopathy\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:36 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: 85 (83 - 90) bpm\n BP: 124/68(82) {115/14(42) - 145/74(91)} mmHg\n RR: 23 (21 - 26) insp/min\n SpO2: 95%\n Height: 67 Inch\n Total In:\n 100 mL\n PO:\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered on right, Diminished: ), prolonged expiratory phase\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, multiple tattoos; multiple ecchymoses\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x 3 , Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 15 K/uL\n 28.2 %\n 9.6 g/dL\n 140 mg/dL\n 1.2 mg/dL\n 83 mg/dL\n 26 mEq/L\n 105 mEq/L\n 5.2 mEq/L\n 143 mEq/L\n 23.0 K/uL\n [image002.jpg]\n 10:30 PM\n WBC\n 23.0\n Hct\n 28.2\n Plt\n 15\n Cr\n 1.2\n Glucose\n 140\n Other labs: PT / PTT / INR:13.7/20.6/1.2, LDH:7200, Ca++:10.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.4 mg/dL\n Imaging: CXR: infiltrate over RML/RLL, fullness right hilum\n Assessment and Plan\n 1. Acute on chronic respiratory failure, hypoxia: Secondary to\n exacerbation of underlying COPD, possible PNA. Seems to have had a more\n crhonic course with cough, ?persistent infiltrates and postobstuctive\n component. Don't have CT from outside hospital (only report) and\n unable to send him off the floor for a CT here given risk for\n hemoptysis and tenuous respiratory status. Concerned for lung mass.\n Will treat with cefepime, atovent nebs, advair, oxygen to maintain sats\n >93%, cup to bedside to quantify hemoptysis, codeine for cough\n suppressant. When more stable from a bleeding/respiratory standpoint,\n consider CT chest.\n 2. TTP vs. : Consult with heme/onc and blood bank team, blood smear\n reviewed. Plan to initiate plasmapheresis, discussed with the patient,\n patient's son/daughter and his friend . Serial labs.\n 3. Thrombocytopenia: be related to TTP/ albeit also concerned\n that this could be drug-induced. Will discontinue levoquin and keppra.\n 4. HTN: Continue lisinopril and metoprolol.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:00 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments: Needs restraints given right groin line and throbocytopenia\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 70 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2178-07-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 582602, "text": "TITLE:\n Chief Complaint: transfer to unit for hypoxia and possible TTP\n HPI:\n Mr. is an 81yo gentleman with h/o transferred from OSH\n with possible TTP.\n He initially presented to Addison- on with complaint of\n shortness of breath with several days of cough. Given his history of\n smoking, he was initially treated as a possible COPD exacerbation. His\n course was complicated by significant hypoxia with oxygen sat's in the\n 80s. CXR demonstrated a RUL infiltrate with concern for hilar mass.\n An Echocardiogram was essentially normal. He was placed on\n levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n On arrival to the floor at , he was hypoxic with O2 sat's around 90%\n on 10L facemask, which then progressed to a non-rebreather\n requirement. He produced about 10cc of blood from his mouth (unclear\n if he coughed this up or if this was from an oropharyngeal bleed). He\n was transferred to the ICU for further care.\n Upon arrival to the ICU, he stated he was breathing comfortably on the\n NRB. He denied any pain.\n The patient's children report that he has had a significant weight loss\n with chronic cough and progressive shortness of breath. Over the\n winter, he lost about 30 pounds but has only gained a small amount of\n the weight back. Around the same time, he developed a persistent,\n hacking cough. The cough improved with a cough suppressant. He had\n some x-rays done at the VA and he was told they had \"seen something\"\n there that was cause for concern. He then had a CT scan about a month\n ago, but the family received conflicting signals as to whether the\n findings were concerning. He was put on antibiotics and there was a\n plan for repeat CT in one month. About two weeks ago, he became\n increasingly fatigued and the cough returned, prompting his admission\n to Addison-.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds on transfer:\n Ondansetron 4 mg IV Q8H:PRN nausea\n Pantoprazole 40 mg PO Q24H\n MethylPREDNISolone Sodium Succ 60 mg IV Q8H\n LeVETiracetam 500 mg PO BID\n Lisinopril 20 mg PO DAILY\n Atenolol 50 mg PO DAILY\n Fluticasone-Salmeterol Diskus (250/50) 1 INH IH \n Lactulose 30 mL PO BID\n Simvastatin 80 mg PO DAILY\n Docusate Sodium 100 mg PO BID\n Senna 1 TAB PO BID:PRN Constipation\n Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain\n Past medical history:\n Family history:\n Social History:\n COPD\n CAD\n HTN\n Dyslipidemia\n Epilepsy\n s/p PPM, unclear indication\n Tobacco abuse\n PCP: \n Not contributory\n Lives with good friend . Smokes 1 PPD. Denies current alcohol\n abuse but is evasive about prior use.\n Review of systems:\n Flowsheet Data as of 12:35 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 85 (83 - 90) bpm\n BP: 123/87(94) {115/14(42) - 145/87(94)} mmHg\n RR: 20 (20 - 26) insp/min\n SpO2: 95%\n Height: 67 Inch\n Total In:\n 100 mL\n PO:\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 250 mL\n 50 mL\n Urine:\n 250 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -150 mL\n -50 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n 95.8 124/37 90 24 95% NRB\n Pleasant, thin man in no acute distress but somewhat tachypneic.\n EOMI, no scleral icterus.\n Mucous membranes coated with blood. Tongue midline.\n Neck supple, no thyroid enlargement or adenopathy.\n S1, S2, RRR, somewhat distant heart sounds.\n Lungs with bronchial breath sounds and wheezes on right, good air\n movement on left.\n Abd: +BS, soft, NT, ND.\n Neuro: Alert, answers questions appropriately, 5/5 strength prox and\n distal UE and LE b/l.\n No LE edema b/l. DP +2 b/l. Extremities are warm with some mild\n clubbing.\n Skin: bruising and multiple tattoos\n Labs / Radiology\n 15 K/uL\n 9.6 g/dL\n 140 mg/dL\n 1.2 mg/dL\n 83 mg/dL\n 26 mEq/L\n 105 mEq/L\n 5.2 mEq/L\n 143 mEq/L\n 28.2 %\n 23.0 K/uL\n [image002.jpg]\n \n 2:33 A6/27/ 10:30 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 23.0\n Hct\n 28.2\n Plt\n 15\n Cr\n 1.2\n Glucose\n 140\n Other labs: PT / PTT / INR:13.7/20.6/1.2, Differential-Neuts:64.0 %,\n Band:12.0 %, Lymph:8.0 %, Mono:12.0 %, Eos:0.0 %, Ca++:10.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.4 mg/dL\n Imaging:\n CT Chest from VA: New consolidation of RUL and LLL with\n mediastinal and right hilar adenopathy, may be infectious. f/u\n recommended to confirm resolution.\n TTE from OSH : EF 60% with borderline concentric LVH, trace TR.\n No effusion.\n CXR (PRELIM): Large right mid lung airspace opacity concerning\n for pneumonia. overall increased opacity of right lung. unilateral\n hemorrhage, edema less likely. left lung clear.\n Assessment and Plan\n 81yo gentleman with h/o COPD who initially presented with shortness of\n breath now transferred to the ICU with anemia and thrombocytopenia\n concerning for TTP.\n # Thrombocytopenia / Possible TTP:\n DDx includes TTP (smear showed schistocytes and labs c/w hemolysis),\n ITP (may be partially treated due to steroids), medication side effect,\n or malignancy. Unlikely to be DIC given normal coags. Currently with\n some evidence of active bleeding, although unclear if hemoptysis or\n oropharyngeal vs GI.\n - will hold off on transfusing platelets unless < 10K as platelets can\n worsen TTP\n - active T&S for possible RBC transfusions\n - stool guaiac\n - appreciate hem/onc input\n - per discussion with team, will place pheresis catheter for emergent\n plasmapheresis\n - monitor Q12H platelets\n - will send HIT antibody per heme\n - will follow CBC with retic, haptoglobin, and fibrinogen\n - will stop all unnecessary meds\n - would transfuse FFP if his clinical status worsens\n # Hypoxia and shortness of breath:\n DDx includes COPD exacerbation, pneumonia, malignancy/lung mass, or\n PE. Would also consider possible diffuse alveolar hemorrhage given\n hemoptysis.\n - continue NRB and would monitor pt closely in ICU (do not feel he is\n stable to leave floor for imaging)\n - send sputum sample for culture\n - treat for possible hospital acquired PNA (steroids could have masked\n fevers) with vanc/cefepime (not zosyn given marrow suppression)\n - continue steroids\n - pt confirms DNR/DNI status\n - if his clinical status improves, would consider bronchoscopy for\n tissue diagnosis of possible mass, though he is unlikely to tolerate\n this\n - cough suppressant\n # COPD:\n - continue atrovent and advair\n # HTN: continue home lisinopril and beta blocker\n # CAD and Dyslipidemia:\n - continue beta blocker and statin\n - will hold ASA\n # Epilepsy:\n - will hold keppra given that there have been some reports of\n pancytopenia or thrombocytopenia with keppra and his seizures sound to\n be more of \"absence\" variety\n # Tobacco abuse:\n - smoking cessation counseling\n # s/p PPM: unclear indication, monitor on tele\n # FEN: NPO for now; replete lytes prn\n # Access: 18g PIV\n # PPx: pneumoboots; switch PPI to famotidine given low platelets\n # Code: DNR/DNI confirmed with patient\n # Comm: per chart, spokesperson is (cell)\n # Dispo: ICU pending stabilization\n" }, { "category": "Nursing", "chartdate": "2178-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582681, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Continues to ooze brb from femoral cath insertion site. Hct 23 this\n am..\n Action:\n Received 1unit RPC.\n Dsg changed, gauze applied.\n Response:\n Awaiting repeat hct\n Plan:\n Monitoring hct and plts. Transfuse platlets if below 10.\n Hypoxemia\n Assessment:\n Pt wearing 95% hi-flow neb..rr 20\ns.. with mask off..sats down to\n 70\npt has strong cough...some insp/exp wheezing..\n Action:\n Getting neb tx..\n Changed o2 to 2l nc and 95% face tent\n Response:\n Maintaining adequate sats with above o2\nmore comfortable with face\n tent.\n Plan:\n To keep sats above 92\nwean o2 as tolerated.\n Hemoptysis\n Assessment:\n Pt coughing more when he turns on his side. No hemoptysis noted this\n shift. Mouth has old brown blood.\n Action:\n Pt being tx for TTP\nto get pherisis tomorrow\n Response:\n Assessing bleeding\n Plan:\n Phersis for TTP If cough becomes to much for pt..can have cough\n suppressant.\n Family in..son and daughter..\n Health care proxy signed by pt and placed in chart.\n" }, { "category": "Nursing", "chartdate": "2178-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582633, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Pt alert ,oriented x 3 , denies any pain, coughed out blood small\n amount clots several times, used yankeur sometimes to clear the mouth\n . unclear whether haemoptysis or bleeding from mouth,or hard palate\n .plt 15, crit 28.2. WBC 23 from PM labs, crit dropped to 23 and plt\n 15 with am labs. .afebrile. voided moderate amount urine. K 5.2\n Action:\n Cefipime 2gm stat given and started with regular dose,waiting for ID\n approval Rt femoral pheresis catheter inserted by Dr. \n and started with plasmapheresis No:1 by haematology RN team\n after the conscent . keyoxalate 30gm po ordered, but he took only\n 15gms. IVF N/s 500c given for hydration.pt NPO . sputum c/s , urine\n c/s sent.\n Response:\n Pt cooperative and tolerated well with the procedure. Vss. Afebrile.\n having bleeding from the pheresis cath site. Pt code status confirmed\n with pt as DNR/DNI . repeat K 4.6\n Plan:\n Continue with monitoring lytes, CBC /bleeding . f/u with haem team for\n pheresis. need blood transfusions.\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 582731, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - acute drop in platelets to 8, transfused 1 unit; posttransfusion\n count 40 with no signs of active bleed (ooze from R groin line)\n - transfusion parameters: platelets less than 10; Hct < 25\n - tolerate plasmapheresis, will repeat daily as per heme/pathology recs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\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 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 109 (90 - 114) bpm\n BP: 121/51(68) {103/37(58) - 151/90(98)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 157 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 157 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 120 mL\n Urine:\n 1,100 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n 37 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 92%\n ABG: ///19/\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 27 K/uL\n 8.9 g/dL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n HYPOXEMIA\n HEMOPTYSIS\n THROMBOTIC THROMBOCYTOPENIC PURPURA / HEMOLYTIC UREMIC SYNDROME\n (HUS/TTP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2178-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582727, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Pt is oozing bld from the pheresis line.Pt had 1 bag of plts in the\n evening.Post tansfusion plt count was 40.\n Action:\n Dressing changed x2.Pt continues to ooze even after that.Pressure\n dressing applied.\n Response:\n Unchanged.\n Plan:\n Monitoring hct and plts. Transfuse platlets if below 10.Pheresis today.\n Hypoxemia\n Assessment:\n Pt was on high flow FM at 95%.Sating 88-92% when pt keeps it on.In the\n am @4am pt became demanding and wanted to go on a commode.Became\n increasingly tachypneic, desating down to low 80\ns, tachycardic.\n Action:\n Attemped to get him out on commode.On the 1^st attempt pt felt dizzy,\n after which pt became more demanding to sit out on commode,On the\n second attempt pt did good with transfer.But pts sats never really came\n up on 95% High flow.So put him on 100% NRB and administered Ativan for\n agitation.Administer ABx as prescribed.\n Response:\n Pt is sating 88-92 % on NRB.\n Plan:\n To keep sats above 97%\nwean o2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 582738, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - acute drop in platelets to 8, transfused 1 unit; posttransfusion\n count 40 with no signs of active bleed (ooze from R groin line)\n - transfusion parameters: platelets less than 10; Hct < 25\n - tolerate plasmapheresis, will repeat daily as per heme/pathology recs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\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 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 109 (90 - 114) bpm\n BP: 121/51(68) {103/37(58) - 151/90(98)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 157 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 157 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 120 mL\n Urine:\n 1,100 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n 37 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 92%\n ABG: ///19/\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 27 K/uL\n 8.9 g/dL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n HYPOXEMIA\n HEMOPTYSIS\n THROMBOTIC THROMBOCYTOPENIC PURPURA / HEMOLYTIC UREMIC SYNDROME\n (HUS/TTP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2178-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582717, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Pt is oozing bld from the pheresis line.Pt had 1 bag of plts in the\n evening.Post tansfusion plt count was 40.\n Action:\n Dressing changed x2.Pt continues to ooze even after that.Pressure\n dressing applied.\n Response:\n Plan:\n Monitoring hct and plts. Transfuse platlets if below 10.Pheresis today.\n Hypoxemia\n Assessment:\n Pt was on high flow FM at 95%.\n Action:\n Getting neb tx..\n Changed o2 to 2l nc and 95% face tent\n Response:\n Maintaining adequate sats with above o2\nmore comfortable with face\n tent.\n Plan:\n To keep sats above 92\nwean o2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2178-07-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 582650, "text": "Chief Complaint: Hypoxemia, respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Continues to cough up or spit up blood and clots.\n Dialysis catheter placed last PM and plasmaphoresis initiated.\n Continues on high dose steroids.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:15 AM\n Infusions:\n Other ICU medications:\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: No(t) Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, 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, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia\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 Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:26 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: 92 (83 - 94) bpm\n BP: 112/54(66) {107/14(42) - 145/87(94)} mmHg\n RR: 20 (19 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 100 mL\n 692 mL\n PO:\n 100 mL\n TF:\n IVF:\n 692 mL\n Blood products:\n Total out:\n 250 mL\n 300 mL\n Urine:\n 250 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -150 mL\n 392 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , Crackles : , No(t) Bronchial: , No(t) Wheezes\n : , Diminished: , No(t) Absent : , No(t) Rhonchorous: ), Prolonged\n expiratory phase\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, Thin\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice, Echymosis\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 15 K/uL\n 156 mg/dL\n 1.3 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 84 mg/dL\n 104 mEq/L\n 147 mEq/L\n 23.8 %\n 19.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n WBC\n 23.0\n 19.9\n Hct\n 28.2\n 23.8\n Plt\n 15\n 15\n Cr\n 1.2\n 1.3\n Glucose\n 140\n 156\n Other labs: PT / PTT / INR:14.4/28.1/1.2, ALT / AST:21/89, Alk Phos / T\n Bili:53/1.4, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:2637\n IU/L, Ca++:10.4 mg/dL, Mg++:2.5 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE -- Acute on chronic respiratory failure, hypoxia:\n Underlying COPD with acute exacerbation and possible PNA. Will treat\n with cefepime, atovent nebs, advair, oxygen to maintain sats >93%, cup\n to bedside to quantify hemoptysis, codeine for cough suppressant. When\n more stable from a bleeding/respiratory standpoint, consider CT chest.\n TTP vs. \n Hematology Consultation and Blood Bank Consultation in\n progress. Continue plasmapheresis and steroids.\n THROMBOCYTOPENIA -- be related to TTP/, but also concerned that\n this could be drug-induced. Will discontinue levoquin and keppra.\n Monitor plts. Transfuse for plts <10k. Avoid meds that may contribute\n to thrombocytopenia.\n LUNG INFILTRATE\n unusual appearance. Although may be component of\n pneumonia or bleeding, concern remains for possible lung mass. Would\n like to obtain chest CT if clinically improves. Currently not safe for\n travel to CT. Will attempt to obtain outside radiographs.\n HEMOPTYSIS - EPISTAXIS\n No escalation. Monitor clinically. No\n indication for intervention.\n ANEMIA\n Likely blood loss. Plan transfuse to Hct >25.\n HTN -- Continue lisinopril and metoprolol if BP increases.\n SEIZURE\n now off meds (Keppra may contribute to thrombocytopenia).\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "ECG", "chartdate": "2178-07-11 00:00:00.000", "description": "Report", "row_id": 233516, "text": "Normal sinus rhythm with occasional ventricular premature beats. Right\nbundle-branch block. Left anterior fascicular block. Compared to tracing #1\nno diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2178-07-11 00:00:00.000", "description": "Report", "row_id": 233517, "text": "Normal sinus rhythm, rate 88, with ventricular premature beats. Leftward\naxis. Right bundle-branch block with left anterior fascicular block. Low\nvoltage in the precordial leads. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2178-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085939, "text": " 5:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion/mass\n Admitting Diagnosis: THROMBOTIC THROMBOCYTOPENIC PUPURA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with hypoxia with concern for TTP vs. effusion\n REASON FOR THIS EXAMINATION:\n r/o effusion/mass\n ______________________________________________________________________________\n WET READ: JXRl SAT 6:00 PM\n large right mid lung airspace opacity concerning for pneumonia, overall\n increased opacity of right lung. unilateral hemorrhage, edema less likely.\n left lung clear. d/w dr 6pm .\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: AP chest, .\n\n HISTORY: 81-year-old man with hypoxia and concern for TTP versus effusion.\n\n FINDINGS: There is a large right mid lung airspace opacity concerning for\n pneumonia. Per report, the patient also has a history of hemoptysis for five\n days. An underlying lesion with post-obstructive consolidation is not\n entirely excluded. Would recommend followup to resolution of this infiltrate\n to exclude an underlying malignancy. There is no pleural effusion. Pacemaker\n is identified.\n\n\n\n\n\n" }, { "category": "Nursing", "chartdate": "2178-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582824, "text": "Hypoxemia\n Assessment:\n Pt. remained on non-rebreather.\n Action:\n Poor pleths. Sats 90-95%. On 100% nrb. Pt. very agitated.\n Tachy[neic and tachycardic. Ho informed.\n Pt. pulling off leads. Reassured.\n Foley placed. With urojet. Urine clear.\n Plasma pheresis not yet started.\n Noted that sats had dropped first to 80\ns-70\ns. noted that pt. was no\n longer breathing.\n Attending and ho\ns notified. Pt. dnr.dni. no interventions. Pt.\n pronounced at 10:30am.\n Family notified that he wasn\nt doing well, but doesn\nt know that he\n expired.\n Response:\n Organ bank notified.\n Plan:\n Awaiting the family. Ho spoke with family. Autopsy declined.\n" }, { "category": "General", "chartdate": "2178-07-13 00:00:00.000", "description": "Brief Death Note", "row_id": 582820, "text": "TITLE:\n Brief Death Note:\n 81 year old gentleman with history of tobacco abuse and COPD who\n initially presented to an outlying hospital with shortness of breath.\n Initially he was diagnosed and treated for a pneumonia but worsening\n thrombocytopenia and anemia prompted transfer to with the\n presumptive diagnosis of TTP. The patient was started on\n plasmapheresis and high dose steriods for TTP and maintained on\n antibiotics for his pneumonia. The patient declined further workup of\n a right retrosternal lung mass suggestive of malignancy. The patient\n initally remained stable, tolerating his treatments without any\n complication. Over the prior 12 hrs. the patient\ns clinical status\n deteriorated rapidly with the development of acute renal failure,\n altered mental staus, worsening hemolytic anemia and thrombocytopenia.\n Respiratory status was tenuous with the patient only maintaining\n saturations in the 80\ns to 90\ns on 100%nonrebreather. Oxygenation\n status did not improve with nebulizer treatments. The patient became\n tachypnic and desaturated. No escalation of care was provided\n according to the patient\ns wishes of DNR/DNI status. The patient went\n into cardiopulmonary arrest and was declared deceased at 11:30 am on\n after checking for pulses, corneal reflex and heart sounds.\n The family was contact and at this time has deferred decision for\n autopsy.\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 582740, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - acute drop in platelets to 8, transfused 1 unit; posttransfusion\n count 40 with no signs of active bleed (ooze from R groin line)\n - transfusion parameters: platelets less than 10; Hct < 25\n - tolerate plasmapheresis, will repeat daily as per heme/pathology recs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\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 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 109 (90 - 114) bpm\n BP: 121/51(68) {103/37(58) - 151/90(98)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 157 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 157 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 120 mL\n Urine:\n 1,100 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n 37 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 92%\n ABG: ///19/\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 27 K/uL\n 8.9 g/dL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n HYPOXEMIA\n HEMOPTYSIS\n THROMBOTIC THROMBOCYTOPENIC PURPURA / HEMOLYTIC UREMIC SYNDROME\n (HUS/TTP)\n Assessment and Plan\n 81yo gentleman with h/o COPD who initially presented with shortness of\n breath now transferred to the ICU with anemia and thrombocytopenia\n concerning for TTP.\n # Thrombocytopenia / Possible TTP:\n DDx includes TTP (smear showed schistocytes and labs c/w hemolysis),\n ITP (may be partially treated due to steroids), medication side effect,\n or malignancy. Unlikely to be DIC given normal coags. Currently with\n some evidence of active bleeding, although unclear if hemoptysis or\n oropharyngeal vs GI.\n - will hold off on transfusing platelets unless < 10K as platelets can\n worsen TTP\n - active T&S for possible RBC transfusions\n - stool guaiac\n - appreciate hem/onc input\n - per discussion with team, will place pheresis catheter for emergent\n plasmapheresis\n - monitor Q12H platelets\n - will send HIT antibody per heme\n - will follow CBC with retic, haptoglobin, and fibrinogen\n - will stop all unnecessary meds\n - would transfuse FFP if his clinical status worsens\n # Hypoxia and shortness of breath:\n DDx includes COPD exacerbation, pneumonia, malignancy/lung mass, or\n PE. Would also consider possible diffuse alveolar hemorrhage given\n hemoptysis.\n - continue NRB and would monitor pt closely in ICU (do not feel he is\n stable to leave floor for imaging)\n - send sputum sample for culture\n - treat for possible hospital acquired PNA (steroids could have masked\n fevers) with vanc/cefepime (not zosyn given marrow suppression)\n - continue steroids\n - pt confirms DNR/DNI status\n - if his clinical status improves, would consider bronchoscopy for\n tissue diagnosis of possible mass, though he is unlikely to tolerate\n this\n - cough suppressant\n # COPD:\n - continue atrovent and advair\n # HTN: continue home lisinopril and beta blocker\n # CAD and Dyslipidemia:\n - continue beta blocker and statin\n - will hold ASA\n # Epilepsy:\n - will hold keppra given that there have been some reports of\n pancytopenia or thrombocytopenia with keppra and his seizures sound to\n be more of \"absence\" variety\n # Tobacco abuse:\n - smoking cessation counseling\n # s/p PPM: unclear indication, monitor on tele\n # FEN: NPO for now; replete lytes prn\n # Access: 18g PIV\n # PPx: pneumoboots; switch PPI to famotidine given low platelets\n # Code: DNR/DNI confirmed with patient\n # Comm: per chart, spokesperson is (cell)\n # Dispo: ICU pending stabilization\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2178-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582747, "text": "81 yo male pt initially presented to Addison- on with\n complaint of shortness of breath with several days of cough. Given his\n history of smoking, he was initially treated as a possible COPD\n exacerbation. His course was complicated by significant hypoxia with\n oxygen sat's in the 80s. CXR demonstrated a RUL infiltrate with\n concern for hilar mass. An Echocardiogram was normal. He was placed\n on levofloxacin for possible pneumonia, although there he did not have\n fevers. In addition, he was put on solumedrol 125mg IV (first day\n ). He began to develop ecchymoses and mild hemoptysis; CBC\n demonstrated marked thrombocytopenia with platelets falling from 93 to\n 15 and Hct dropped from 40 to 29. He had an abdominal ultrasound that\n did not show any evidence of cirrhosis. Hematology was consulted and\n became concerned about the possibility of TTP given moderate\n schistocytes on his smear; he was therefore transferred to for\n further care.\n Thrombotic Thrombocytopenic Purpura / Hemolytic Uremic Syndrome\n (HUS/TTP)\n Assessment:\n Pt is oozing bld from the pheresis line.Pt had 1 bag of plts in the\n evening.Post tansfusion plt count was 40.\n Action:\n Dressing changed x2.Pt continues to ooze even after that.Pressure\n dressing applied.\n Response:\n Unchanged.\n Plan:\n Monitoring hct and plts. Transfuse platlets if below 10.Pheresis today.\n Hypoxemia\n Assessment:\n Pt was on high flow FM at 95%.Sating 88-92% when pt keeps it on.In the\n am @4am pt became demanding and wanted to go on a commode.Became\n increasingly tachypneic, desating down to low 80\ns, tachycardic.\n Action:\n Attemped to get him out on commode.On the 1^st attempt pt felt dizzy,\n after which pt became more demanding to sit out on commode,On the\n second attempt pt did good with transfer.But pts sats never really came\n up on 95% High flow.So put him on 100% NRB and administered Ativan for\n agitation.Administer ABx as prescribed.\n Response:\n Pt is sating 88-92 % on NRB.\n Plan:\n To keep sats above 97%\nwean o2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 582795, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Overnight experienced clinical decline, with worsening respiratory\n distress and hypoxemia, requiring increased FiO2.\n Experienced worsening renal function.\n Experienced bleeding from right femoral dialysis catheter. Received\n plts transfusion, with rise to 40K, then decline to 27k.\n More tachycardia, sinus.\n More confusion and aggitation early this AM.\n Preparing for plasmaphoresis #2 this AM.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 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 Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, 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, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, No(t) Delirious, No(t)\n Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 107 (90 - 114) bpm\n BP: 87/59(64) {87/37(58) - 151/90(98)} mmHg\n RR: 22 (19 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 196 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 196 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 340 mL\n Urine:\n 1,100 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///19/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : Right posterior, No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, Thin\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 27 K/uL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE -- Acute on chronic respiratory failure, hypoxia:\n Underlying COPD with acute exacerbation and possible PNA. Will treat\n with cefepime, atovent nebs, advair, oxygen to maintain sats >90%, cup\n to bedside to quantify hemoptysis, codeine for cough suppressant. When\n more stable from a bleeding/respiratory standpoint, consider CT chest.\n TTP vs. \n Overall clinical decline, now with worsening mental\n status and renal failure. Hematology Consultation and Blood Bank\n Consultation following. Continue plasmapheresis and steroids.\n RENAL FAILURE -- may be prerenal, as with limited intake. Possibly\n related to TTP. Plan iv fluid bolus, monitor UO, BUN, creatinine.\n ALTERED MENTAL STATUS -- possibly related to TTP, but may be medication\n related (steroids), pardoxical effect of benzodiazepine, ICU\n psychosis. Less likey EtOH related, although remote possibility for\n DTs.\n THROMBOCYTOPENIA -- be related to TTP/, but also concerned that\n this could be drug-induced. Will discontinue levoquin and keppra.\n Monitor plts. Transfuse for plts <10k. Avoid meds that may contribute\n to thrombocytopenia.\n LUNG INFILTRATE\n unusual appearance. Although may be component of\n pneumonia or bleeding, concern remains for possible lung mass. Would\n like to obtain chest CT if clinically improves. Currently not safe for\n travel to CT. Will attempt to obtain outside radiographs.\n HEMOPTYSIS - EPISTAXIS\n No escalation. Monitor clinically. No\n indication for intervention.\n ANEMIA\n Likely blood loss. Plan transfuse to Hct >25.\n HTN -- Continue lisinopril and metoprolol if BP increases.\n SEIZURE\n now off meds (Keppra may contribute to thrombocytopenia).\n Monitor.\n NUTRITIONAL SUPPORT -- would like to encourage suppliments or consider\n TF (although thrombocytopenia).\n DNR/DNI -- need to confirm direction of care, and assess limitations of\n treatments.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 582800, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Overnight experienced clinical decline, with worsening respiratory\n distress and hypoxemia, requiring increased FiO2.\n Experienced worsening renal function.\n Experienced bleeding from right femoral dialysis catheter. Received\n plts transfusion, with rise to 40K, then decline to 27k.\n More tachycardia, sinus.\n More confusion and aggitation early this AM.\n Preparing for plasmaphoresis #2 this AM.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 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 Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, 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, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, No(t) Delirious, No(t)\n Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 107 (90 - 114) bpm\n BP: 87/59(64) {87/37(58) - 151/90(98)} mmHg\n RR: 22 (19 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 196 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 196 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 340 mL\n Urine:\n 1,100 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///19/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : Right posterior, No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, Thin\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 27 K/uL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE -- Acute on chronic respiratory failure, hypoxia:\n Underlying COPD with acute exacerbation and possible PNA. Will treat\n with cefepime, atovent nebs, advair, oxygen to maintain sats >90%, cup\n to bedside to quantify hemoptysis, codeine for cough suppressant. When\n more stable from a bleeding/respiratory standpoint, consider CT chest.\n TTP vs. \n Overall clinical decline, now with worsening mental\n status and renal failure. Hematology Consultation and Blood Bank\n Consultation following. Continue plasmapheresis and steroids.\n RENAL FAILURE -- may be prerenal, as with limited intake. Possibly\n related to TTP. Plan iv fluid bolus, monitor UO, BUN, creatinine.\n ALTERED MENTAL STATUS -- possibly related to TTP, but may be medication\n related (steroids), pardoxical effect of benzodiazepine, ICU\n psychosis. Less likey EtOH related, although remote possibility for\n DTs.\n THROMBOCYTOPENIA -- be related to TTP/, but also concerned that\n this could be drug-induced. Will discontinue levoquin and keppra.\n Monitor plts. Transfuse for plts <10k. Avoid meds that may contribute\n to thrombocytopenia.\n LUNG INFILTRATE\n unusual appearance. Although may be component of\n pneumonia or bleeding, concern remains for possible lung mass. Would\n like to obtain chest CT if clinically improves. Currently not safe for\n travel to CT. Will attempt to obtain outside radiographs.\n HEMOPTYSIS - EPISTAXIS\n No escalation. Monitor clinically. No\n indication for intervention.\n ANEMIA\n Likely blood loss. Plan transfuse to Hct >25.\n HTN -- Continue lisinopril and metoprolol if BP increases.\n SEIZURE\n now off meds (Keppra may contribute to thrombocytopenia).\n Monitor.\n NUTRITIONAL SUPPORT -- would like to encourage suppliments or consider\n TF (although thrombocytopenia).\n DNR/DNI -- need to confirm direction of care, and assess limitations of\n treatments.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 582801, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Overnight experienced clinical decline, with worsening respiratory\n distress and hypoxemia, requiring increased FiO2.\n Experienced worsening renal function.\n Experienced bleeding from right femoral dialysis catheter. Received\n plts transfusion, with rise to 40K, then decline to 27k.\n More tachycardia, sinus.\n More confusion and aggitation early this AM.\n Preparing for plasmaphoresis #2 this AM.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 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 Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, 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, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, No(t) Delirious, No(t)\n Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 107 (90 - 114) bpm\n BP: 87/59(64) {87/37(58) - 151/90(98)} mmHg\n RR: 22 (19 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 196 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 196 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 340 mL\n Urine:\n 1,100 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///19/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : Right posterior, No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, Thin\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 27 K/uL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE -- Acute on chronic respiratory failure, hypoxia:\n Underlying COPD with acute exacerbation and possible PNA. Will treat\n with cefepime, atovent nebs, advair, oxygen to maintain sats >90%, cup\n to bedside to quantify hemoptysis, codeine for cough suppressant. When\n more stable from a bleeding/respiratory standpoint, consider CT chest.\n TTP vs. \n Overall clinical decline, now with worsening mental\n status and renal failure. Hematology Consultation and Blood Bank\n Consultation following. Continue plasmapheresis and steroids.\n RENAL FAILURE -- may be prerenal, as with limited intake. Possibly\n related to TTP. Plan iv fluid bolus, monitor UO, BUN, creatinine.\n ALTERED MENTAL STATUS -- possibly related to TTP, but may be medication\n related (steroids), pardoxical effect of benzodiazepine, ICU\n psychosis. Less likey EtOH related, although remote possibility for\n DTs.\n THROMBOCYTOPENIA -- be related to TTP/, but also concerned that\n this could be drug-induced. Will discontinue levoquin and keppra.\n Monitor plts. Transfuse for plts <10k. Avoid meds that may contribute\n to thrombocytopenia.\n LUNG INFILTRATE\n unusual appearance. Although may be component of\n pneumonia or bleeding, concern remains for possible lung mass. Would\n like to obtain chest CT if clinically improves. Currently not safe for\n travel to CT. Will attempt to obtain outside radiographs.\n HEMOPTYSIS - EPISTAXIS\n No escalation. Monitor clinically. No\n indication for intervention.\n ANEMIA\n Likely blood loss. Plan transfuse to Hct >25.\n HTN -- Continue lisinopril and metoprolol if BP increases.\n SEIZURE\n now off meds (Keppra may contribute to thrombocytopenia).\n Monitor.\n NUTRITIONAL SUPPORT -- would like to encourage suppliments or consider\n TF (although thrombocytopenia).\n DNR/DNI -- need to confirm direction of care, and assess limitations of\n treatments.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section ------\n MICU Attending Addendum:\n During morning rounds, prior to initiating Plasmaphoresis run #2, pt.\n experienced respiratory arrest. Pt. DNR/DNI. Quietly and peacefully\n expired. Family contact.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:58 ------\n" }, { "category": "Physician ", "chartdate": "2178-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 582774, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - acute drop in platelets to 8, transfused 1 unit; posttransfusion\n count 40 with no signs of active bleed (ooze from R groin line)\n - transfusion parameters: platelets less than 10; Hct < 25\n - tolerate plasmapheresis, will repeat daily as per heme/pathology recs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 12:19 AM\n Infusions:\n Other ICU medications:\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 05:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.3\nC (95.5\n HR: 109 (90 - 114) bpm\n BP: 121/51(68) {103/37(58) - 151/90(98)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 2,194 mL\n 157 mL\n PO:\n 720 mL\n TF:\n IVF:\n 840 mL\n 157 mL\n Blood products:\n 634 mL\n Total out:\n 1,100 mL\n 120 mL\n Urine:\n 1,100 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,094 mL\n 37 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 92%\n ABG: ///19/\n Physical Examination\n General: agitated, responding to internal stimuli, follows some\n commands\n HEENT: PERRL icterus, EOMI\n CV: RRR S1 S2\n Lungs: tachypnic, bilateral wheezes, bronchial breath sounds\n Abdomen: soft/ NT/ND +BS\n Ext: +2 DP b/l\n Labs / Radiology\n 27 K/uL\n 8.9 g/dL\n 282 mg/dL\n 1.5 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 101 mEq/L\n 147 mEq/L\n 26.1 %\n 31.9 K/uL\n [image002.jpg]\n 10:30 PM\n 05:12 AM\n 05:09 PM\n 08:30 PM\n 04:15 AM\n WBC\n 23.0\n 19.9\n 21.4\n 31.9\n Hct\n 28.2\n 23.8\n 26.9\n 26.1\n Plt\n 15\n 15\n 8\n 40\n 27\n Cr\n 1.2\n 1.3\n 1.5\n Glucose\n 140\n 156\n 282\n Other labs: PT / PTT / INR:14.0/22.8/1.2, ALT / AST:29/162, Alk Phos /\n T Bili:58/2.3, Differential-Neuts:78.0 %, Band:4.0 %, Lymph:8.0 %,\n Mono:6.0 %, Eos:0.0 %, Fibrinogen:224 mg/dL, Albumin:3.4 g/dL, LDH:5370\n IU/L, Ca++:10.2 mg/dL, Mg++:2.8 mg/dL, PO4:7.4 mg/dL\n Assessment and Plan\n HYPOXEMIA\n HEMOPTYSIS\n THROMBOTIC THROMBOCYTOPENIC PURPURA / HEMOLYTIC UREMIC SYNDROME\n (HUS/TTP)\n Assessment and Plan\n 81yo gentleman with h/o COPD who initially presented with shortness of\n breath now transferred to the ICU with anemia and thrombocytopenia\n concerning for TTP.\n # Thrombocytopenia / Possible TTP:\n DDx includes TTP (smear showed schistocytes and labs c/w hemolysis),\n ITP (may be partially treated due to steroids), medication side effect,\n or malignancy. Unlikely to be DIC given normal coags. Currently with\n some evidence of active bleeding, although unclear if hemoptysis or\n oropharyngeal vs GI.\n - will hold off on transfusing platelets unless < 10K as platelets can\n worsen TTP\n - active T&S for possible RBC transfusions\n - stool guaiac\n - appreciate hem/onc input\n - per discussion with team, will place pheresis catheter for emergent\n plasmapheresis\n - monitor Q12H platelets\n - will send HIT antibody per heme\n - will follow CBC with retic, haptoglobin, and fibrinogen\n - will stop all unnecessary meds\n - would transfuse FFP if his clinical status worsens\n # Hypoxia and shortness of breath:\n DDx includes COPD exacerbation, pneumonia, malignancy/lung mass, or\n PE. Would also consider possible diffuse alveolar hemorrhage given\n hemoptysis.\n - continue NRB and would monitor pt closely in ICU (do not feel he is\n stable to leave floor for imaging)\n - send sputum sample for culture\n - treat for possible hospital acquired PNA (steroids could have masked\n fevers) with vanc/cefepime (not zosyn given marrow suppression)\n - continue steroids\n - pt confirms DNR/DNI status\n - if his clinical status improves, would consider bronchoscopy for\n tissue diagnosis of possible mass, though he is unlikely to tolerate\n this\n - cough suppressant\n # COPD:\n - continue atrovent and advair\n # HTN: continue home lisinopril and beta blocker\n # CAD and Dyslipidemia:\n - continue beta blocker and statin\n - will hold ASA\n # Epilepsy:\n - will hold keppra given that there have been some reports of\n pancytopenia or thrombocytopenia with keppra and his seizures sound to\n be more of \"absence\" variety\n # Tobacco abuse:\n - smoking cessation counseling\n # s/p PPM: unclear indication, monitor on tele\n # FEN: NPO for now; replete lytes prn\n # Access: 18g PIV\n # PPx: pneumoboots; switch PPI to famotidine given low platelets\n # Code: DNR/DNI confirmed with patient\n # Comm: per chart, spokesperson is (cell)\n # Dispo: ICU pending stabilization\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Pheresis Catheter - 12:34 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2178-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582805, "text": "Hypoxemia\n Assessment:\n Pt. remained on non-rebreather.\n Action:\n Poor pleths. Sats 90-95%. On 100% nrb. Pt. very agitated.\n Tachy[neic and tachycardic. Ho informed.\n Pt. pulling off leads. Reassured.\n Foley placed. With urojet. Urine clear.\n Plasma pheresis not yet started.\n Noted that sats had dropped first to 80\ns-70\ns. noted that pt. was no\n longer breathing.\n Attending and ho\ns notified. Pt. dnr.dni. no interventions. Pt.\n pronounced at 10:30am.\n Family notified that he wasn\nt doing well, but doesn\nt know that he\n expired.\n Response:\n Plan:\n Awaiting the family.\n" } ]

[ { "category": "Radiology", "chartdate": "2119-06-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1016377, "text": " 4:27 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for fx, dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n eval for fx, dislocation\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n INDICATION: 80-year-old woman post fall, evaluate for fracture.\n\n COMPARISON: .\n\n FINDINGS: Cardiac silhouette is normal. The aorta is tortuous. There is no\n focal consolidation, pleural effusion or pneumothorax. Pulmonary vascularity\n is normal. Osseous structures are diffusely demineralized. Again note is\n made of exaggerated thoracic kyphosis.\n\n IMPRESSION:\n 1. No evidence of acute cardiopulmonary process.\n 2. Diffuse demineralization, no evidence of displaced fracture.\n\n" }, { "category": "Radiology", "chartdate": "2119-06-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1016370, "text": " 4:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for fx, ICH\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p fall on coumadin, + facial trauma\n REASON FOR THIS EXAMINATION:\n eval for fx, ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:33 PM\n Nasal fracture. Study limited by motion. No acute intracranial hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: Post fall, on Coumadin, with ecchymosis.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage, edema, mass,\n shift of normally midline structures or hydrocephalus. Density values of the\n brain parenchyma are within normal limits.\n\n There is opacification of the right maxillary sinus, and a fluid level in the\n left maxillary sinus. Ethmoid air cells appear opacified. There is nasal\n bone fracture. Facial bone fractures are described in the separate report of\n a maxillofacial CT.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n\n 2. For detailed description of facial bones fractures please refer to\n separate report of sinus CT.\n\n" }, { "category": "Radiology", "chartdate": "2119-06-22 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1017226, "text": " 9:50 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o carotid stenosis\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p fall, c/o dizziness prior to fall\n REASON FOR THIS EXAMINATION:\n r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID DUPLEX.\n\n INDICATIONS: 80-year-old female status post fall with complaints of dizziness\n preceding. Rule out carotid stenosis.\n\n RIGHT:\n\n B-mode imaging of the right distal common carotid, internal and external\n carotid arteries was performed. This demonstrates minimal amounts of\n heterogenous plaque at the carotid flow divider only. This does not appear to\n contribute any significant stenosis. The right common carotid artery waveform\n is normal with peak systolic velocity of 112 cm/sec. The internal carotid\n artery waveform has a preserved systolic window and peak systolic velocity of\n 93 cm/sec. The end-diastolic velocity is 24 cm/sec. The ICA/CCA ratio on the\n right is 0.83. By velocity criteria, this would correlate with a less than\n 40% stenosis. External carotid velocities are 65 cm/sec.\n\n LEFT:\n\n B-mode imaging of the left common carotid and carotid bifurcation shows a\n small amount of heterogenous plaque at the origin of the internal carotid\n artery. This does not appear to create significant stenosis. The left common\n carotid artery waveform is within normal limits and has peak systolic\n velocities of 112 cm/sec. The internal carotid artery waveform has some mild\n spectral broadening and peak systolic velocity of 118 cm/sec. The\n end-diastolic velocity is 16 cm/sec. The left ICA/CCA ratio is 1.0. By\n velocity criteria, this suggests a less than 40% stenosis. The external\n carotid artery velocity is 91 cm/sec.\n\n Both vertebral arteries have antegrade flow with monophasic waveforms.\n\n IMPRESSION:\n\n Mild plaque at the origin of both internal carotid arteries with less than 40%\n stenosis.\n\n No previous studies are available for comparison.\n\n (Over)\n\n 9:50 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o carotid stenosis\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2119-06-15 00:00:00.000", "description": "B WRIST (AP & LAT) SOFT TISSUE BILAT", "row_id": 1016376, "text": " 4:27 PM\n WRIST (AP & LAT) SOFT TISSUE BILAT; HAND (AP, LAT & OBLIQUE) BILATClip # \n Reason: eval for fx, dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p fall onto wrist\n REASON FOR THIS EXAMINATION:\n eval for fx, dislocation\n ______________________________________________________________________________\n FINAL REPORT\n THREE VIEWS OF THE LEFT HAND, THREE VIEWS OF THE RIGHT HAND, THREE VIEWS OF\n THE RIGHT WRIST AND THREE VIEWS OF THE LEFT WRIST.\n\n INDICATION: 80-year-old woman with fall onto the wrist. Evaluate for\n fracture or dislocation.\n\n FINDINGS: There is generalized demineralization, limiting evaluation for\n small nondisplaced fractures. There is no evidence of acute fracture or\n dislocation. Degenerative changes with joint space narrowing and osteophytes\n are noted in the left third and fourth distal interphalangeal joints and fifth\n proximal interphalangeal joint, as well as the fourth right proximal\n interphalangeal joint. Soft tissue swelling is noted around the most affected\n joints.\n\n There is no radiopaque foreign body or soft tissue calcifications.\n\n IMPRESSION:\n 1. No acute fracture or dislocation.\n 2. Severe demineralization with evidence of osteoarthritis.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-06-15 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1016371, "text": " 4:17 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p fall on coumadin, + facial trauma\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:22 PM\n no acute fracture or abnormal alignment in the cervical spine\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: Trauma.\n\n COMPARISON: None available.\n\n NON-CONTRAST CERVICAL SPINE CT: There is no acute fracture or abnormal\n listhesis. Osseous structures are diffusely demineralized. There is\n exaggerated cervical lordosis. Atlantoaxial and atlanto-occipital\n relationships are maintained. Prevertebral soft tissues are unremarkable. The\n airway is patent. Fluid-filled balloon, related to packing is noted in the\n nasopharynx. Small amount of secretions seen in the airways.\n\n Imaged lung apices are clear.\n\n Facial bone fractures are described in detail in the separate report of\n maxillofacial CT, dated .\n\n IMPRESSION:\n 1. No evidence of acute fracture or abnormal alignment of the cervical spine.\n\n 2. For detailed description of the facial bones fractures, please see\n separate report of sinus CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-06-15 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1016372, "text": " 4:18 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P FALL ON COUMADIN, FACIAL TRAUMA.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p fall on coumadin, + facial trauma, lac to nose\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:46 PM\n Fractures of nasal bones bilaterally, anterior nasal spine, anterior nasal\n septum, non-displaced fractures of the left lateral, anterior and medial\n and right anterior and lateral maxillary sinus walls. Displaced fracture of\n the medial wall of the right maxillary sinus.\n ______________________________________________________________________________\n FINAL REPORT\n CT SINUS WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 80-year-old woman post fall on Coumadin, presenting with facial\n bruising, nasal laceration.\n\n COMPARISON: Not available.\n\n TECHNIQUE: Contiguous axial images were acquired through the paranasal\n sinuses. Coronal reformatted images were obtained. No intravenous contrast\n was administered.\n\n FINDINGS: There are nondisplaced fractures of the nasal bones bilaterally,\n anterior nasal septum, and anterior nasal spine. There are nondisplaced\n fractures of the left lateral, medial and anterior wall of maxillary sinus as\n well as lateral and anterior walls of the right maxillary sinus. There is a\n displaced fracture of the medial wall of the right maxillary sinus. There is\n leftward deviation of the nasal septum, of uncertain chronicity.\n\n The inferior orbital wall, lamina papyracea, pterygoid plates, as well as\n zygomatic arches are intact. There is blood in the maxillary sinuses\n bilaterally, nasal cavity as well as ethmoid air cells.\n\n The globes are intact with no vitreous hemorrhage. There is extensive\n preseptal soft tissue swelling, however, there is no retrobulbar hematoma. The\n lenses are in place. There is no mandible fracture. The evaluation of the\n alveolar ridge is limited by significant artifact from dental hardware.\n\n There is packing material in the patient's right nasal cavity with two fluid\n filled balloons, one in the nasopharynx and another one just the very anterior\n aspect of the nasal cavity, as confirmed with clinical team.\n\n IMPRESSION: Multiple facial bone fractures, including nasal bones\n bilaterally, anterior nasal septum, anterior nasal spine, medial, lateral and\n anterior walls of maxillary sinuses bilaterally.\n\n\n (Over)\n\n 4:18 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P FALL ON COUMADIN, FACIAL TRAUMA.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2119-06-21 00:00:00.000", "description": "Report", "row_id": 194506, "text": "Atrial fibrillation with slow ventricular response. Non-specific ST-T wave\nchanges. Possible septal myocardial infarction, age indeterminate. Compared\nto the previous tracing of the ventricular rate is slower. QRS change\nhas occurred in lead V2.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-06-16 00:00:00.000", "description": "Report", "row_id": 1464573, "text": "adm note\n80 y old female came in from ED midnight . she fell last night onto her face w/o LOC. hx of a/fib , on coumadin and digoxin at home. she suffered a broken nose and ?fractured maxillary bones. heavy nose bleeding, with INR 2.2, was nasaly packed in ED both nares and given 2U FFP and vit K,\n\nassessment as noted\n\nneuro: intact since arrival to the unit, pinpoint pupils/, , a+ox3, turns in bed , cooperative, denies pain\n\nres: Pt has sever pigion chest deformity, LS clear, sat 97 on ra, was put on coolmist for providing moisture to dry mouth\n\ncv: remains in a/fib, on digoxin qd, bp stable, + pulses,\n\ngi: vomited dark partially clotted blood, denied nausea after that episode. asked for food but was explained to patient that she is NPO\n\ngu: void on bedpan clear yellow\n\nskin: face is bruised with large hematoma around both eyes and nose, l.foot has pink area that looks like old heeling decube\n\nlabs: hct range since 4pm : 37-> 26->24->23\n\nsocial: no family , next of is an old coworker\n\nplan: repeat ct on facial /sinuses, monitor hct, neuro status, mouth care., nasal packing is to stay for 5 days\n" }, { "category": "Nursing/other", "chartdate": "2119-06-16 00:00:00.000", "description": "Report", "row_id": 1464574, "text": "no significant events today.\n\nneuro- pt alert and oriented, OOB with minimal assist. steady gait. tol well. c/o h/a. tylenol given with little effect, morphine 1mg given IV with good effect. needs PT consult\n\nCV- afib, rate 80-90. b/p wnl. + pedal pulses. pt refused pt boots most of day. repeate crit pending. FE ordered for low crit.\n\nresp- room air sat 98. lung sounds clear. pigion chest, kyphotic back.\n\nGI/GU- abd soft + bs, ordered for a reg diet, but pt only taking sips of clears and some applesauce with meds due to difficulty swallowing from nasal packing. no aspiration. + nausea and scant emesis, old blood swallowed from trauma. voiding on bedpan. IVF d5 20k 60/hr\n\nID- clinda restarted for facial fx.\n\nskin- facial brusing and contusions, eyes swollen. nasal packing in left nare balloon in right.\n\nsocial- friends in to visit.\n\nplan- to remain in T/SICU for monitoring untill tomorrow. nasal packing to saty X5 days. advance diet as tol and HL IVF when taking good amt. PT consult pending. monitor crit\n\n" }, { "category": "Nursing/other", "chartdate": "2119-06-17 00:00:00.000", "description": "Report", "row_id": 1464575, "text": "NPN 7a-7p\n\nno significant events\n\nNeuro- alert and oriented no c/o pain. more up beat and talkative.\n\nCV- remains in a-fib rate 70-80, on lopressor and dig. b/p 140's.\n\nresp- lung sounds clear, r/a sat 98-100%\n\nGI/GU- abd soft. swallowing better, taking soft diet and liquids. + stool. bloody from old digested blood from accident. voiding well. lytes replaced. IVF cont D51/2 20k 60/hr.\n\nSkin- contusions to face, pedal edema,old healed stage 2 to Left inner ankle.\n\nENT- ENT MD in to see pt. clot removed from back of throat. packing to remain for 5 days ( 3 more days)\n\nplan- increase po intake as tol. packing to be removed by ent in 3 days for a total of 5 day packed. ? transfer to floor in am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-06-18 00:00:00.000", "description": "Report", "row_id": 1464576, "text": "Nursing Progress Note\nSee Carevue/Transfer Note for specific Data.\n\nSignificant Events: Pt taking adequate POs, Maintenance fluid discontinued. Pt ambulated through unit this evening, tolerated very well.\n\nNeuro: A & O x3, MAE's with full strength, follows all commands, communicates verbally without issues.\n\nPain: Pt had no pain throughout shift, expresses that she is feeling much better/comfortable.\n\nCV: Afib, HR 80-110's. BP 120-150 systolic, MAP WNL. Easily palpable pedal pulses, PBoots on. Digoxin & lopressor continues.\n\nResp: Lung sounds clear throughout, maintaining O2 sat >97% on RA. Balloon/packed nares to remain for 5 days total (2 more).\n\nGI: Abdomen soft, not distended, nontender. +BS, +small BM in evening (melena/liquid). Colace refused/held due to frequent BMs. Tolerating PO's well, eating/drinking more.\n\nGU: Adequate clear, yellow urine output-pt voids/bedside commode.\n\nEndo: Moderate amounts of insulin required per RISS, BS 305 at 04:00. Tighten Insulin sliding scale.\n\nID: Afebrile, Cefazolin continues.\n\nSocial: No calls/visitors overnight. Pt very pleasant and appreciative of care. Good spirits overnight. Slept well.\n\nPlan: Tighten RISS. Manage pain as needed. Ambulate pt. Encourage IS/deep breathing. Change lopressor IV standing dose to PO. Continue to support pt. Transfer pt to floor.\n" }, { "category": "Nursing/other", "chartdate": "2119-06-18 00:00:00.000", "description": "Report", "row_id": 1464577, "text": "HCT 21.5, HO aware. Possible 1 unit PRBCs?\n" } ]

[ { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930127, "text": "NICU NSG NOTE\n\n\n#1. Sepsis. O/ Awake and alert with cares. Temps stable\nsince transitioning into servo isolette. Conts on ampi and\ngent. A/ No overt s/s sepsis. P/ Cont to monitor for s/s\nsepsis.\n\n#2. Resp. O/ Received infant on vent settings 22/5 x20.\nInfant weaned to 21/5 x18 at 1600 secondary to 2pm CBG. FIO2\nthis shift 27-33%. RR 30-50's. LS coarse. IC/SubC\nretractions. Infant had one spontaneous desat to 60's\nrequiring increased O2 to recover. A/ Soewhat labile. P/\nCont to monitor resp status closely. Wean settings as\ntolerated.\n\n#3. FEN. O/ Wt down 150g (had been up 25g from birth). NPO.\n D10W with additives now at 80cc/k/d. UO this shift\n0.8cc/k/h (from >3.6cc/k/h earlier today). DS 67. Abd exam\nbenign. No stool. A/ ALt in FEN r/t prematurity. P/ Cont to\nmonitor I&O's. Lytes in am.\n\n#4. G&D. O/ Awake and alert with cares. Transitioned into\nservo isolette with stable temps. Cares clustered. Nested on\nsheepskin. Boundaries in place. A/ AGA. P/ Cont to support\ndevelopmental needs of infant.\n\n#5. Parenting. O/ Dad in during change of shift. Spoke with\nhim briefly at bedside. States he was updated by NNP. Plans\non visiting tomorrow with his paretns. Mom to visit on Sun\nor Mon when she is d/c from MW. Dad reports other sibling is\ndoing well. A/ Updated. Stressful situation for family. P/\nCont to provide info and support to family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-23 00:00:00.000", "description": "Report", "row_id": 1930128, "text": "NPN:\n\nRESP: SIMV-20/5 x 14 (24-29% 02). Rate weaned from 16->14 following CBG of 7.32/ 35/ 44/ 19/ -7. RR=50-60s with SC/IC retraction. Sx'd q 4 h for sm-mod amt cloudy secretions from ETT. BBS =/ooarse.\n\nCV: No murmur. HR=120-130s. BP=61/30 (40). Color pink w/good perfusion.\n\nFEN: Wt=2455g (- 150g). NPO. TF=80cc/kg/d. iV of D-10-W w/ NaCl 2mEq, KCl 1mEq/100cc. Abd benign. U/O=2.5cc/kg/h over 24-h period yesterday; 2.0cc/kg/h over past 8 h. No stool since yesterday. Elec: 145/ 4.0/ 112/ 19. Dx=70.\n\nBILI: Bili 10.1/ 0.3/ 9.8 (up from 6.1).\n\nG&D: CGA=34 wk. Temp stable in servo-controlled isolette. Active and alert w/good tone. AF soft, flat. Nested in sheepskin and resting well.\n\nID: Remains on Amp & Gent (day 3). To obtain cx results from today.\n\nSOCIAL: No contat w/parents.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-23 00:00:00.000", "description": "Report", "row_id": 1930129, "text": "Respiratory Care\nBaby rec'd on 21/5,R 18. Weaned to 20/5, R16. BS coarse. Sxn for sm-mod amts cldy/ white sec. RR 30's-60's. CBG: 7.32/35/44/19/-7; rate further weaned to 14. No spells noted, but sats labile, esp with handling. Will cont to follow, support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-23 00:00:00.000", "description": "Report", "row_id": 1930130, "text": "Neonatology Attending\n\nDOL 3 PMA 34 3/7 weeks\n\nS/P surf x 3 and now weaned to low vent settings. Currently on 23-33%/20/5/14. R 30s-60s. CBG 7.32/35/44 on rate of 16. Has lability with sats requiring adjustments in FiO2.\n\nNo murmur. BP 72/46 mean 54.\n\nNPO on IV D10+lytes at 80 ml/kg/d. Voiding 2.5 ml/kg/hr. Stooling. 145/4/112/19 DS 70. Wt 2455 grams (down 150).\n\nBili 10.1/0.3. type O+/Coombs neg.\n\nOn A/G. BC NGSF.\n\nFather visiting. Mother still in the hospital. Other twin is now in RA and doing well.\n\nA: Stable. Resolving RDS. Sepsis ruled out.\n\nP: Monitor\n Extubate today\n Start feeds\n Advance to 100 ml/kg/d\n Check lytes in am\n Follow bili\n D/C A/G\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-23 00:00:00.000", "description": "Report", "row_id": 1930131, "text": "NNP Physical Exam\nPE: pink, mild jaundice, AFOF, sutures override, orally intubated, breath sounds clear/equal with fair to good air entry, mild retracting, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-23 00:00:00.000", "description": "Report", "row_id": 1930132, "text": "NPN 0700-1900\n\n\nSEPSIS: NNP- to contact : cx. If\ncx is negative, then abx will be d/c'd.\n\nRESP: Rec'd infant orally intubated on settings of 20/5 x\n14, FIO2 28-35%. Breath sounds are coarse w/ fair to good\nair entry. No retractions noted. RR 50-60's.\n Extubated to CPAP-6cm and FIo2 has remained in the same\nrange. No increased work of breathing noted. Infant\ncontinues to desat w/ crying ( but also had while\nintubated). Responds slowly to increased FIO2. Breath\nsounds are unchanged. No bradycardia noted.\nA/P: Monitor wob closely s/p extubation. Follow FIo2\nrequirement\n\nF&N: TF increased to 100cc/kg/d. Enteral feeds started at\n40cc/kg/d at 1300. Infant tolerated NG feeds well. No\nspits or aspirates. Abd is round and soft w/ active bowel\nsounds and no loops. AG is 25cm. No stool passed this\nshift. U/o=1.7cc/kg/hr x 8hrs. + mild edema noted. Lytes\nto be checked in am.\n in right hand continues to infuse D10w w/ 2meq\nNACl/1meq KCL without incident at 60cc/kg/d.\nA/P: Monitor u/o closely. Will check D/s this evening s/p\ndecreased IVF. Assess tolerance to feeds\n\nG&D: Infant is alert and airritable when awake. Temp is\nstable. Changed isolette to air mode and infant dressed and\nswaddled. Tone is appropriate. Skin is intact. PKU to be\ndone in am.\n\nPARENTS: Mom called for an update this morning. She will\nremain hospitalized until Monday. SHe is pumping and sent\nsome BM here w/ . came in this afternoon w/ his\nparents to visit. He was updated at the bedside and took\nvideo and pictures for Mom. said he will be in to visit\ntomorrow afternoon as well and can be best reached by cell\nphone , if needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-23 00:00:00.000", "description": "Report", "row_id": 1930133, "text": "Respiratory Care\nPt extubated today and placed on +6cmH2O prong CPAP. Fio2 .30-.35. bs clear, rr 50-70 with mild retractions. req increased O2 with aggitation/crying. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-24 00:00:00.000", "description": "Report", "row_id": 1930134, "text": "NICU NSG NOTE\nADDENDUM\n\nBili this am 14.4/0.3. Started on single phototherapy at 0400. Eye shields in place.\n\nUO for 24h 2.7cc/k/h.\n\nPKU sent this shift.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-24 00:00:00.000", "description": "Report", "row_id": 1930135, "text": "NICU NSG NOTE\n\n\n#2. Resp. O/ Received pt on Prong CPAP 6 25-30%. Trialing on\nNC as of MN. Currently on NC 200cc, 40%. LS clear and equal.\nNo GFR. RR 30-60's. No spells. No increased wob noted since\ntrial to NC. A/ Stable in NC. P/ Cont to monitor resp status\nclosely. Wean O2 as tolerated.\n\n#3. FEN. O/ Wt down 15g. TF 100cc/k/d. Enteral feeds\nadvanced at 0030 to 60cc/k/d. Receiving q4h volumes PE20 via\ngavage over 30 mins. Abd soft and flat. No loops or spits.\n+BS. Max asp 3cc. Remainder of fluids D10W with additives\nvia RH at 40cc/k/d. DS 65. A/ Tolerating feeding\nadvancement. P/ Cont to monitor for feeding intolerances.\nDaily wts. Advance feeds by 20cc/k as tolerated.\n\n#4. G&D. O/ Awake and alert with cares. Irritable at times,\nbut likes pacifier. Temps stable in weaning air isolette.\nMAE. Nested and swaddled. Cares clustered. A/ AGA. P/ Cont\nto support developmental needs of infant.\n\n#5. Parenting. No contact from family thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-24 00:00:00.000", "description": "Report", "row_id": 1930136, "text": "Respiratory Care\nBaby rec'd on prong CPAP 6. BS clear. Placed on NC @ 200cc @ 30-40% @ ~midnight. No increased WOB or spells. Will monitor.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-24 00:00:00.000", "description": "Report", "row_id": 1930137, "text": "Neo Attending\n4 dy, 34.4 wk\nRespr: s/p IMV, Surf; on cpap, off cpap to nc: 75-100 cc at FiO2 100%\nrr 30-60s; clear =BS; no spells.\nno murmur;\nHR 120-140s, mean 56. well perfused.\nBili 14/4/0.3 on photoRx since 4 am on .\n2440, down 15,\nTF 100cc/kg/day enteral 60 cc/kg/day. incr to 80 cc/kg/day enterally.\nIV 40 cc/kg/day. Advance total fluids min of 120-130 cc/kg/day. Keep IV at 40 cc/kg/day and enteral at 35 cc per feed =120 cc/kg/day\nglu nl.\nabd wnl. took po 35 cc per bottle. UOP 2.7 cc/kg/hr, stooled.\nlytes wnl. NB state screen, PKU done.\nless irritable.\n\nAssess: Infant is ready to go to Hospital Level II Nursery if bed is available, accepted, and permission for transport and assuming infant remains as stable as he has shown.\nPlan: tranfer as noted if possible. continue neonatal plan.\n\nInfant examined and discussed with team.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-24 00:00:00.000", "description": "Report", "row_id": 1930138, "text": "NURSING TRANSFER NOTE\n\n\n was transferred in to from \ndue to worsening resp distress. He was transferred in on\nCPAP- 75% fio2. He was intubated and rec's 3 doses of\nSurfactant. He was extubated at noon yesterday,, to\nCPAP-6cm- 40%. Stable work of breathin s/p extubation w/\nsome to 50-80's when he cried that resolved quickly\nw/ increased fio2. No overnihgt. Infant was placed\non NCO2 at midnight. O2 requirement has weaned to present\nrequirement of 75-100cc, 100%. He has no retractions. RR\n30-60's. Breath sounds are clear and equal. No apnea or\nbradycardia noted.\n\nF&N: BW-2580gms, wt today-2440gms, down 15gms. Tf were\nincresed to 120cc/kg/d. Infant is advancing on enteral\nfeeds. He was increased by 20cc/kg to present\n80cc/kg/d=34cc q4hrs at 0800. Infant bottled full volume at\n0830 and was gavage fed at 1230. He has tolerated feeds\nwell. No spits. Max aspirate-3cc last night. He has been\nfed mostly PE20 but Mom plans to feed as well.\n His abd is soft and flat w/ active bowel sounds and no\nloops. He has stooled since birth but not in past 24hrs.\nHe has mild peripheral edema but urine output is\nincreasing(3.2cc/kg/hr for past 8hrs).\n in right hand is infusing D10w w/2meq NACL/1meq KCL at\n40cc/kg/d= 4.3cc/hr. D/s overnight have been stable at\n65-73. Lytes this am- 143/4.5/108/23.\nA/P: next feeding on q4hrs is at 1630. Due to increase\nenteral feeds by 20cc/kg at .\n\nBILI: Infant is pink/jaundiced. Bili this am-14.4/0.3-\ninfant was placed under single phototheray at 0400. To have\nbili checked in am.\n\nDEV: Infant is alert and active, slightly irritable. His\ntemp is stable in servo-isolette ( he had been swaddled\nprior to phototherapy) at skin temp of 36.1 degrees. Loves\nhis pacifier.\n\nPKU was sent ( consent for testing obtained via phone\nconsent w/ Mom on \n\nInfant has been examined and cleared for transfer to\n. Transport consent obtained by phone consent w/\n. Ambulance booked for 3pm.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-24 00:00:00.000", "description": "Report", "row_id": 1930139, "text": "Neo Attending Discharge summary\n34 wk GA, BW 2.58 infant (Twin A) admitted to NICU due to\nrespr distress.\n\nMat Hx: Details at . Brief summary: 35 yr G4P0 (now 2). IVG twins. Previous pregnancies notable for Trisomy 21 and 22.\nNl chromosomes for this pregnancy's twins. EDC: .\nAneg, Ab neg, RPR nr, GBS unk.\nBedrest x 12 wks due to PIH, +, + antiphospholipid ab, developed pre-eclampsia. Delivery by c/s due to evolving HELLP syn with decrease in plt. (no LFTs available). Mother Rx with Dexamethasone 45 min prior to delivery. AROM at delivery.\n\nCourse Summary:\n: D0 BW 2.58 kg;\n: D1 adm wt: 2.6kg\n: D4 2440gm (down 15 from ).\n\nFEN: NPO, IV PN fluids advanced from 60 to 100 cc/kg/day (). Began enteral feeds on at 40 cc/kg/day. By , enteral feeds up to 60 cc/kg/day. Infant is hungry, po fed well this am (35 cc). Advance total fluids to 110 cc/kg/day (enteral feeds to 80 cc/kg/day + IV fluids at 30 cc/kg/day). Monitor glu with IV wean. Advance feeds and total fluids as tolerated. PO as tolerated.\nElectrolytes: stable. : Na 145, K 4, Cl 112, HCO3 19.\nGlucose\n\nUOP and stooling and abd exam wnl.\n\nRespr: HMD. On CPAP, fio2 75% on admission. Intubated, mechanical ventilation from through 05; surfactant Rx x 3. Weaned to CPAP and NC on . As of , on NC 75 -100 cc/min with FiO2 100%. RR 30-50s. Clear=BS. comfortable.\n\nCV: no murmur. BP and HR wnl.\n\nApnea/ Bradycardia: none\nDesaturations: Infant was labile with cares upon admission, improved thereafter. stable SpO2 in NC O2.\n\nBili: 6.1/0.3; : 10.1/0.3; : 14.4/ 0.3, PhotoRx began. Continue photoRx. Infant is O+, direct coomb's negative. Mother is A neg.\n\nHeme: CBC from : Hct 57%, WBC 11,100; Plt 228K. 42N, 1B.\n\nID: R/O Sepsis: no evidence of positive cultures obtained at . discontinue Amp/ Gen.\n\nDischarge exam as NNP and attending:\nAttending exam: comfortable, in NAD, well perfused, pink.\nHEENT: with bili blinders on. Previous HEENT exam wnl. NC, AF soft, flat.\nNeck wnl. Chest: clear =BS, CV wnl., no murmur, pulses wnl.\nAbd soft, nondistended. Gu: nl pt male. Anus: wnl Back wnl.\nExtrem wnl. Skin: underphototherapy, jaundice.\nNeuro: nl tone, activity, strength for GA.\n\n\nAssessment: 34 wk GA now approaching 35 wk.\nResolve RDS.\nJaundice Rx phototherapy\nNo evidence of sepsis.\nTolerating advancment in feeds.\nNo apnea/ bradycardia. No caffeine.\n\nPlan: Transfer to to continue convalesing premature care.\nContinue regimen of CVR/SpO2 monitoring, IV fluids and advance po feeds, monitor glu with IV wean. D/C amp/gen. Cont photoRx and monitor Bili.\n\n\n SCN aware of transfer. NNP spoke with Dr. . I will speak with Resident.\n" }, { "category": "Radiology", "chartdate": "2116-05-21 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 872057, "text": " 8:55 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ett position, evaluate lung \n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant newly intubated\n REASON FOR THIS EXAMINATION:\n ett position, evaluate lung \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 1-day old who is newly intubated.\n\n COMPARISON STUDIES: None are available.\n\n FINDINGS: An endotracheal tube with the tip just below the thoracic inlet\n with the patient's neck flexed. An enteric tube with the tip projected over a\n left-sided stomach. The lungs appear moderately hypo-aerated with diffuse,\n bilateral pulmonary parenchymal opacities. They have a granular appearance\n that is slightly coarse. The pulmonary vascularity appears normal. Prominence\n of the cardiothymic silhouette is likely attributable to thymus and degree of\n aeration. The bony thorax is intact. Surrounding structures are\n unremarkable.\n\n IMPRESSION:\n\n 1. Slightly high, but satisfactory positioning of endotracheal tube.\n Satisfactory positioning of enteric tube.\n\n 2. Findings that are compatible with hyaline membrane disease (surfactant\n deficiency syndrome). Neonatal pneumonia could also have this appearance.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930122, "text": "Neonatology Note\nDOL #2, CGA 34 wks.\n\nCVR: Currently on SIMV 22/5 x 20, 24-36%. Received two doses of surfactant overnight following intubation. Last CBG 7.26/56/26/-2. Somewhat tachypnic with increased work of breathing. Labile oxygen saturations. Hemodynamically stable.\n\nFEN: BW 2580, currently weight 2605 grams. NPO, TF 60 cc/kg/day, D10 2 Na. Lytes 142/4.0/108/20. Dstiks 101, 88. Voiding 3.3, stooling.\n\nID: CBC from MW 11.1>57<228, 42N/1B. cx sent. Amp/gent.\n\nGI: Bili 6.1/0.2. Mom /Infant O+/Coombs -.\n\nDEV: On warmer.\n\nIMP: 34 wk twin with RDS, on moderate SIMV support. Hemodynamically stable. Doubt sepsis.\n\nPLANS:\n- Continue SIMV.\n- 3rd dose of surf.\n- Target O2sats 92-98%, given lability and advanced gestational age.\n- Mild fluid restriction at 60.\n- Lytes, bili in am.\n- Continue amp/gent, pending 48 hours cultures.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930123, "text": "Case Management Note\nHave reviewed cahrt to date and evnts noted. We will be assessing what type of health insurance family has as none listed as of now. I will place EIP & VNA options in record and will cont to follow for any d'c planning needs w/team & family.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930124, "text": "NURSING PROGRESS NOTE\n\n\n1 - POT SEPSIS - PT TEMP HIGH X1 = PROBE ADJUSTED ON WARMER.\n PT ALERT W/ CARES. TO CONTINUE ON AMP AND GENT AS ORDERED.\n\n2 - RESP - PT RECEIVING INTUBATED ON SETTINGS: 22/5, X20\n30%. BREATH SOUNDS CRSE - TO CLEARING AFTER SXN, MILD SC/IC\nRETRACTIONS. SXN - MOD WHITE SECRETIONS FROM ETT. GIVEN\nTHIRD DOSE OF SURVANTA AT 1500. CBG TO BE DRAWN THIS\nAFTERNOON\nA/P; CONT YO MONITOR, CBG DUE IN AFTERNOON\n\n3 - FEN - NPO. TF=60CC/K OF D10 W/ 2NA, INFUSING VIA \nWITHOUT DIFFICULTY. ABD SOFT, PINK, +BS. PT =\n3.6CC/K/HR TODAY, LG MEC STOOL.\nA/P; CONT TO FOLOW, LYTES IN AM, DAILY WT\n\n4 - G/D - TEMP STABLE - WARM X1 - PROBE REPLACED, TEMP\nSTABILIZED. PT NESTED, WAKEFUL SLIGHT IRRITABLE W/ CARES,\nSETTLING BETWEEN CARES. AFOF.\n\n5 - PARENT - MOM CALLING X1 - UPDATED BY OTHER RN. AWARE OF\nSTATUS. MOM AND DAD W/ TWIN AT .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930125, "text": "Neonatology-NNP Progress Note\n\nDad in and updated regarding Allistar's progress. Reviewed clinical issues, criteria for transfer back to or home. Given parents packet and reassurred. Mom remains in house at and may visit on Sunday. Dad has photos, we will continue to keep informed.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930126, "text": "Respiratory Care Note\nInfant remains on IMV with current settings of 21/5, R18, FIO2's 27-33% with increased requirement for cares. ETT retaped for security 8.5cm at lip. BS coarse - clearing after sx of mod white secretions. CBG at ~1400 was 7.32/43/31/23/-4 (on 22/5, R20) with vent wean. 3rd does of Survanta given at 1125 tol fair with reflux - PPV given to disperse Survanta. Small audible air leak - continue to monitor, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930116, "text": "LATE ENTRY FOR \n\nNeonatal NP-Procedure Note\n\nProcedure: Intubation\nIndication: Airway managment\n\ntime out observed. Infant positioned and with direct laryngoscopy placed a 3.0 ett through trachea without difficulty. Infant tolerated procedure well. Xray demonstrated good placement with ground glass appearance to lung .\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930117, "text": "1 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930118, "text": "2 Respiratory\n3 Fluid & nutrition\n4 Growth & development\n5 Parenting\n\nREVISIONS TO PATHWAY:\n\n 2 Respiratory; added\n Start date: \n 3 Fluid & nutrition; added\n Start date: \n 4 Growth & development; added\n Start date: \n 5 Parenting; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930119, "text": "Admission Note\nBB () is 34 wk GA, Twin A (sister- is Twin B) with BW 2.58 kg transferred from to NICU due to increasing respr distress and need for respr management and ongoing neonatal care as related to prematurity.\n\nMat Hx: 35 yr g 4 p 0 to 2. IVF twins. Mother's previous pregnancies notable for Trisomy 21 and 22 conceptions which were treminated.\n Nl chromosomes for each twin. EDC . A neg, Ab neg, GBS unk, RPR nr.\nMother was on bed rest x 12 weeks due to PIH. +, + antiphospholipid Ab. Mother admitted to MW due to preclampsia (Proteinuria). Delivery at ~8pm by stat C/S due to HELLP syndrome (low plt). Mother Rx with Dexamethasone ~ 45 min prior to delivery. AROM at delivery.\n\nInfant: Apgars . Increasing respr distress at 4 hr age with increasing FiO2 requirement. CXR c/w RDS. Placed on CPAP 5 + increased FiO2. R/O sepsis Rx with Amp and Gen. B/C pending. CBC wnl. Hct 56 WBC 11 (nl diff), plt 228K. Electrolytes wnl. glucose screens wnl. voided and stooled. Baby is O+ (direct coombs pending at ).\n\nOver the course of evening and day, infant had persistent and increasing respr distress. At time of transfer, infant was on CPAP 75% FiO2 with SpO2 mid-high 90s, pink, active. Transferred to due to expectation that infant would need mech ventilation and surfactant Rx.\n\nUpon admission to NICU at :\nAdm Wt 2.605 kg HC 34.5 cm\nT =99.8 P 180s to 130s, RR 70s on CPAP with 75% FiO2. SpO2 labile in 80-90s. BP =78/24.\nInfant appears well perfused but having moderate respr distress.\nHEENT: wnl based on external exam. Chest: BS dimiished bilaterally, CPAP sounds audible. CV: S1 S2 split, no murmur, pulse and perfusion wnl. Abd wnl. GU wnl. ANus: passing mec. Skin: mild jaundce.\nNeuro: active infant. Extrem wnl.\nCXR c/w moderate HMD.\nINfant intubated ~8pm, 1st surf @ 2100, 2nd dose 3 am on .\nInfant weaned on his FiO2 from 40% to 26%. BG improving: pH 7.31, pCO2 20. Wean PIP and rate. Will follow CXR in am, blood gases.\nUOP and stool wnl.\nBili total 6.1/ 0.3, electrolytes wnl 140/4.0, 108, HCO 25.\nInfant on IV of D10W at 60 cc/kg/day.\n\nAssessment:\n 34 wk AGA Twin with HMD, s/p surf x 2.\nR/O sepsis: doubt. Infant on Abx. If cultures are neg after 48 hr, would d/c abx.\nBAby Rh +, mother Rh neg. Direct Coombs pending.\n\nPlan: Adjust Mech Vent as necessary. Wean as tolerated.\nNPO at this time. Begin TPN on .\nID- Amp/Gen as noted above.\nBili: follow juandice and direct coombs.\n\nInfant attended since admission, examined, and discussed with NICU team. Spoke with the mother regarding status and care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930120, "text": "Admission Note\nBaby admitted to warmer after transport from . Received baby in 5cm prong CPAP, 75% O2. Baby has in R hand infusing D10W @ 80cc/k/d. Baby weighed & placed on warmer. Breath sounds diminished. Decision made to intubate. Baby orally intubated by NNP & placed on 26/5 X's 24. ist dose of survanta given. CXR done for placement. Breath sounds equal & coarse with mild IC retractions. VSS (see flow sheet). IV fluids changed to D10w 2meq NaCl/100cc & total fluids decreased to 60cc/k/d. DS 101 & 88. Lytes, bili & coombs drawn. UOP for past 12 hrs was 3.4cc/k/h. Abd soft with active bowel sounds & no loops. Passing mec stools with each diaper change. Baby had cultures drawn at & is on antibiotics. Baby rec'd 2nd dose of survanta at 3AM. Baby is presently in 30% o2, 22/5, X's20. Breath sounds remain coarse with mild IC retractions. Baby with cares requiring inc O2. Dr spoke with mother on phone & updated her. Baby is nested on sheepskin on warmer. Fontanelles soft & flat. Alert with cares.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-22 00:00:00.000", "description": "Report", "row_id": 1930121, "text": "Respiratory Care\nBaby rec'd on 26/6, R 25. ABG: 7.31/47/72/25/-2; no changes made. Labile 02 sats. BS coarse. Sxn for sm amts white sec as per flowsheet. Rec'd 2nd dose of Survanta @ 0300- tol well. ABG: 7.32/34/40/18/-7; parameters weaned as per flowsheet. CBG @ 0600 on R 20, 22/5: 7.26/56/38/26/-2; no further changes made. 02 req 25-36%. Will cont to follow closely, assess for need for additional dosing of , wean vent as tol.\n" }, { "category": "Nursing/other", "chartdate": "2116-05-21 00:00:00.000", "description": "Report", "row_id": 1930115, "text": "Respiratory Care\nPt transferred in from . Intubated with 3.0 oet taped @ 8.5cm marking. Rec'd first dose survanta @2030hr. Tol well. Currently on settings 26/6 x24. Fio2 .55. BS coarse/=,fair air entry. rr 60-80. cxr pending for ett placement. Plan to wean as tol. Will follow.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2185-05-06 00:00:00.000", "description": "Report", "row_id": 1630973, "text": "Focus: Status Update\nData:\nPatient is at times hard to arouse and will not open eyes unless very strongly stimulated such as sternal rub. When he does open his eyes he focuses on speaker. Then other times he just opens eyes when you stimulate him lightly.He is non-verbal but at times grunts. Does follow commands inconsistently such as squeezing with left hand and moving legs. Weaker right side. Right pupil 1mm and left pupil 2mm, both sluggish.\n\nLungs bilaterally clear. Weak cough. Episode of desat to 90 which improved with increase in O2. Small periods of apnea, <15sec, with snoring.\n\nNipride drip started to maintain BP<140, small dose of .25mcg/kg/min accomplishes this easily but quickly becomes hypertensive without it.\n\nPlan:\nQ1hr neuro checks. Wean Nipride as tlerated to keep BP<140. Possible repeat CT.\n" }, { "category": "Radiology", "chartdate": "2185-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1014361, "text": " 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with prior CXR showing question of infiltrate w/ persistent\n fever\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Persistent fever.\n\n Portable AP chest radiograph was compared to .\n\n The NG tube passes below the diaphragm most likely terminating in the stomach.\n The heart size is normal. Mediastinal contours are unremarkable. Bibasilar\n opacities are unchanged and might represent atelectasis vs. pneumonia.\n Calcified diaphragmatic pleural plaques are again noted and might represent\n prior asbestos exposure.\n\n" }, { "category": "Radiology", "chartdate": "2185-05-08 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1013868, "text": " 12:54 PM\n PORTABLE ABDOMEN Clip # \n Reason: Placement of NG tube\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with stroke\n REASON FOR THIS EXAMINATION:\n Placement of NG tube\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, 1:07 P.M., \n\n HISTORY: Stroke. NG tube placed.\n\n IMPRESSION: AP view of the torso centered at the diaphragm shows nasogastric\n tube ending in the upper stomach, and moderate distention of large and small\n bowel in the upper abdomen. If there is concern for obstruction, routine\n abdominal series showed be requested.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-05-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1013677, "text": " 3:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eavluate for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with large right frontal ICH, smaller left ICH and increased\n right arm weakness.\n REASON FOR THIS EXAMINATION:\n eavluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with large right frontal intracranial hemorrhage,\n smaller left intracranial hemorrhage, increased right arm weakness, evaluate\n for interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: The large right intraparenchymal hemorrhage with associated edema,\n mass effect, and effacement of the right frontal of the lateral ventricle\n is unchanged. A 4 mm leftward shift of normally midline structures is stable.\n Diffuse subarachnoid hemorrhage within the cortical sulci is also largely\n unchanged. A more confluent area of hemorrhage within the left parietal lobe\n likely reflects subarachnoid blood. There continues to be blood layering\n within the occipital horns of the lateral ventricles bilaterally. Mild\n ventriculomegaly with dilated temporal horns, likely reflecting mild\n hydrocephalus, is unchanged from .\n\n No new focus of hemorrhage is identified. There is no definite evidence of an\n acute infarct. Paranasal sinuses and mastoid air cells are unremarkable.\n Osseous structures are within normal limits.\n\n IMPRESSION:\n 1. Allowing for differences in slice selection, there is no significant\n change in the large right intraparenchymal hemorrhage, diffuse subarachnoid\n hemorrhage, and intraventricular blood.\n\n 2 Stable mild shift of normally midline structures.\n\n 3. Stable mild ventriculomegaly, with dilatation of the temporal horns.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-05-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1013490, "text": " 12:20 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: please perform scsan at 12 noon, please eval for evolution o\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man w/intracranial hemorrhage\n REASON FOR THIS EXAMINATION:\n please perform scsan at 12 noon, please eval for evolution of intracranial\n hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:03 PM\n slight interval increase in the right frontal intraparenchymal hemorrhage and\n bilateral SAH. unchanged 4.9 mm subfalcine herniation, and intraventricular\n hemorrhage. no hydrocephalus. no uncal or downward transtentorial herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with intracranial hemorrhage, perform scan at 12\n noon, evaluate for evolution of intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Again is noted a large right frontal intraparenchymal hemorrhage,\n slightly larger than the study conducted at 3:00 a.m. this morning. There is\n associated subarachnoid hemorrhage, comparable to the prior study. Unchanged\n bilateral intraventricular extension is again noted. There is extensive\n vasogenic edema surrounding the hemorrhage causing mass effect and effacement\n of the frontal and occipital horns of the lateral ventricle. There is a 4.9\n mm leftward subfalcine herniation compared to prior 4.4 mm. There is no uncal\n or downward transtentorial herniation. There is diffuse global atrophy,\n unchanged. There are no acute major vascular territorial infarcts or obvious\n masses. There is no hydrocephalus. No other interval changes are noted.\n\n IMPRESSION:\n 1. Slight interval increase in the right frontal intraparenchymal and\n bilateral subarachnoid hemorrhage.\n 2. Stable intraventricular hemorrhage and minimal leftward subfalcine\n herniation.\n\n" }, { "category": "Radiology", "chartdate": "2185-05-05 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1013422, "text": " 5:51 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please eval for amyloid angiopathy, underlying stroke, tumor\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with ICH\n REASON FOR THIS EXAMINATION:\n please eval for amyloid angiopathy, underlying stroke, tumor\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with intracranial hemorrhage, evaluate for amyloid\n angiopathy, underlying stroke, or tumor.\n\n COMPARISON: CT head, .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted MR images of the head were\n obtained prior to and after IV gadolinium contrast. Sagittal MP-RAGE post-\n contrast images along with axial and coronal reformatted images were also\n obtained.\n\n FINDINGS: Again demonstrated is a large right frontal intraparenchymal\n hemorrhage, measuring approximately 5.5 cm x 5 cm, not significantly changed\n in size from three hours prior. This lesion demonstrates mostly T2\n hyperintensity and T1 isointensity, compatible with an acute hemorrhage. There\n is associated mass effect on the frontal of the right lateral ventricle\n with mild subfalcine herniation, not significantly changed.\n\n Additionally, a moderate amount of layering intraventricular hemorrhage within\n the occipital horns of the lateral ventricles is stable. Thre is no evidence\n of hydrocephalus. On gradient-echo sequences, scattered punctate foci of\n susceptibility are seen within the sulci, likely reflecting blood products\n from a small amount of associated subarachnoid hemorrhage.\n\n No definite enhancement is seen within the right frontal region to suggest a\n large mass or vascular malformation. However, given the relatively large size\n of this, assessment is somewhat limited. Additionally, there is no evidence of\n an acute infarct within any particular vascular territory. No convincing\n evidence of amyloid angiopathy is identified. Minimal mucosal thickening of\n the ethmoidal sinuses is seen. No abnormal enhancement is identified after\n contrast administration.\n\n IMPRESSION:\n\n 1. Large right frontal intraparenchymal hemorrhage, with associated\n subarachnoid and intraventricular hemorrhage. Overall size and appearance is\n largely unchanged from three hours prior.\n\n 2. Mild leftward subfalcine herniation and effacement of the right frontal\n and lateral ventricle is not changed.\n\n 3. No definite evidence of underlying mass, vascular malformation, or\n (Over)\n\n 5:51 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please eval for amyloid angiopathy, underlying stroke, tumor\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n infarct. No convincing evidence of amyloid angiopathy. However, due to the\n large size of this hemorrhage, assessment is limited for an underlying lesion,\n and a followup study after resolution of acute symptoms is recommended to\n exclude any underlying mass or vascular malformation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-05-05 00:00:00.000", "description": "CHEST (PRE-OP AP ONLY)", "row_id": 1013421, "text": " 5:39 AM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: preop\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with ICH\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with intracranial hemorrhage. Preoperative\n evaluation.\n\n No comparison studies.\n\n AP UPRIGHT CHEST RADIOGRAPH: The heart is at the upper limits of normal in\n size. Mediastinal and hilar contours are unremarkable. The lungs are clear.\n There is no pleural effusion. Right greater than left pleural plaques are\n demonstrated, consistent with prior asbestos exposure.\n\n IMPRESSION: No acute cardiopulmonary process. Likely prior asbestos\n exposure.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-05-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1014212, "text": " 6:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Hydrocephalus? Edema? Midline shift?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with large R frontal bleed, now not waking up properly.\n REASON FOR THIS EXAMINATION:\n Hydrocephalus? Edema? Midline shift?\n CONTRAINDICATIONS for IV CONTRAST:\n no indication\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: 79-year-old man with large right frontal bleed, now not awakening\n properly, question hydrocephalus, edema or midline shift.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the head were obtained\n without intravenous contrast.\n\n COMPARISON: .\n\n FINDINGS: The large right intraparenchymal hemorrhage with associated edema,\n mass effect and effacement of the right frontal of the lateral ventricle\n have shown expected evolution from prior study without any evidence of new\n hemorrhage or infarct. The 4-mm leftward midline shift is unchanged. The\n diffuse subarachnoid blood within the cortical sulci is similar, although the\n confluent area in the left parietal lobe is less apparent. There is slightly\n less blood within the occipital horns of lateral ventricles than on prior. The\n mild ventriculomegaly and dilated temporal horns is similar to prior.\n\n There is new opacification of the left sphenoid sinus. The mastoid air cells\n are normal. There are no fractures.\n\n IMPRESSION:\n 1. Expected evolution of right intraparenchymal hemorrhage and diffuse\n subarachnoid hemorrhage and intraventricular blood without evidence of new\n infarct or intracranial hemorrhage.\n 2. Persistent midline shift.\n 3. No change in the mild ventriculomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2185-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1013685, "text": " 4:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pos NGT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with SAH, IPH, IVH s/p NGT placement\n REASON FOR THIS EXAMINATION:\n ?pos NGT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Nasogastric tube assessment.\n\n Examination is limited by exclusion of the periphery of the right lung from\n the study, sufficient for the purpose of documenting nasogastric tube\n placement. Nasogastric tube tip terminates in the region of the\n gastroduodenal junction. Imaged portion of the chest is without change from\n the recent study.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1014024, "text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Infiltration? PNA?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with R frontal stroke, high fever\n REASON FOR THIS EXAMINATION:\n Infiltration? PNA?\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 79-year-old man with right frontal stroke and high fever. Evaluate\n for infiltrate and pneumonia.\n\n FINDINGS:\n\n The left hemidiaphragm is more ill-defined on today's examination secondary to\n a left basilar infiltrate. There is a curvilinear pleural calcification\n involving the right hemidiaphragm. The lungs are low in volume. The heart\n size is normal. A feeding tube tip is in the stomach.\n\n IMPRESSION:\n\n A left lower lobe opacity could either represent atelectasis or infectious\n consolidation. Short-term follow up examination is recommended.\n\n 2) Single calcified right hemidiaphragmatic pleural plaque.\n\n" }, { "category": "ECG", "chartdate": "2185-05-05 00:00:00.000", "description": "Report", "row_id": 216534, "text": "Sinus rhythm. Intraventricular conduction delay of right bundle-branch block\ntype. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2155-04-15 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 962131, "text": " 11:00 AM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: r/o fx\n Admitting Diagnosis: MULTIPLE RIB FXS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with left knee pain\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain.\n\n Three radiographs of the left knee demonstrate a moderate knee joint effusion.\n There is linear sclerosis along the medial tibial plateau. No depression of\n the overlying tibial plateau is evident. Small spur is seen along the\n inferior aspect patella. Regional soft tissues are unremarkable. The joint\n spaces are maintained on nonweightbearing views. Regional soft tissues are\n unremarkable. There is evidence of old MCL trauma.\n\n IMPRESSION:\n Linear sclerosis involving the medial tibial plateau. While the finding may\n simply represent a prominent region of the physeal scar, nondisplaced tibial\n plateau fracture is not excluded, particularly in the setting of moderate knee\n joint effusion. Assessment with cross-sectional imaging is recommended.\n\n Old MCL trauma.\n\n Mild patellofemoral compartment osteoarthritis.\n\n Moderate knee joint effusion.\n\n Findings were discussed with physician assistant on at\n 1:30 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-14 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 961926, "text": " 12:02 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: c-spine ligamentous injury\n Admitting Diagnosis: MULTIPLE RIB FXS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with neck pain s/p motorcycle crash, no injury on ct.\n REASON FOR THIS EXAMINATION:\n c-spine ligamentous injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DDH MON 1:51 AM\n neg acute finding;\n deg changes and spondylosis c5-6 and c6-7\n md\n ______________________________________________________________________________\n FINAL REPORT\n MR CERVICAL SPINE\n\n HISTORY: Motor vehicle accident with normal cervical spine CT. Rule out\n ligamentous injury.\n\n Sagittal imaging was performed with long TR, long TE fast spin echo, short TR,\n short TE spin echo, and STIR technique. Axial long TR, long TE fast spin\n echo, and gradient echo imaging was performed. Comparison to a cervical spine\n CT of .\n\n FINDINGS: The study is limited by motion artifact. There are degenerative\n changes, most marked at C4-5 with canal narrowing and probable encroachment on\n the spinal cord, although this is poorly evaluated due to motion. The study\n is of limited reliability for detecting ligamentous injury. No definite\n ligamentous tears are detected. However, there is a small amount of tissue\n edema or fluid anterior to the C3 through C5 vertebral bodies. This may\n represent hemorrhage, perhaps suggesting a ligamentous compromise. If there\n is clinical suspicion of ligamentous injury, a follow up MR examination may be\n helpful.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 961833, "text": " 10:02 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: MOTORCYCLE ACCIDENT.PAIN.R/O FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with\n REASON FOR THIS EXAMINATION:\n +loc, was in a motorocycle accident. known rib, scapula and spinal fractures,\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SAT 11:06 PM\n no fracture identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle accident.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the cervical spine were obtained with\n coronal and sagittal reformatted images.\n\n CT C-SPINE: The alignment is normal with no antero- or retro-listhesis. There\n are multilevel degenerative changes. No definite fracture is seen. There is\n no prevertebral soft tissue swelling. There is paraseptal emphysema.\n Posterior lung opacities are better evaluated on the dedicated CT torso.\n\n IMPRESSION: No fracture identified. No listhesis.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 961834, "text": " 10:02 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: +loc, was in a motorocycle accident. known rib, scapula and\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with\n REASON FOR THIS EXAMINATION:\n +loc, was in a motorocycle accident. known rib, scapula and spinal fractures,\n PLS DO RECON'S\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SUN 9:31 AM\n BONES:\n 1) Right Rib posterior fractures\n 2) Right Rib anterior fractures.\n 3) T6-11 left transverse process fractures.\n 4) L1-4 left transverse process fractures.\n\n 5) Antero-lateral right T9 vertebral body fracture.\n 6) Minimal anterior compression fracture of L1 vertebral body fracture\n affecting\n 7) Right lateral/inferior fracture of L4 vertebral body.\n 8) Bilateral inferior and superior pubic ramus fractures.\n 9) Comminuted left scapular fracture.\n\n\n 10) Several tiny foci of air in the right pleural space and mediastinum\n anteriorly\n 11) Posterior lung opacities\n 12) Left psoas muscle expansion secondary to hematoma.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Motorcycle accident. Known rib, scapula, and spinal fractures.\n\n COMPARISON: No comparisons available on PACs.\n\n TECHNIQUE: MDCT-aquired images of the chest, abdomen, and pelvis obtained\n after the administration of IV contrast.\n\n CT OF THE CHEST WITH IV CONTRAST: The aorta and great vessels appear intact.\n There is slight stranding in the mediastinal fat with multiple small lymph\n nodes, including an 8-mm high peratracheal node and an 8-mm precarinal node.\n There is no pericardial effusion. There are multiple small foci of\n intrapleural air with small foci of pneumothorax on the right anteriorly.\n There is paraseptal emphysema. There are patchy posterior opacities in both\n upper lobes and lower lobes.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a small focus of air anterior to\n the liver near the fractured anterior rib (series 2 image 65) that appears to\n be located within the adjacent soft tissues. There is another focus of air\n (Over)\n\n 10:02 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: +loc, was in a motorocycle accident. known rib, scapula and\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n adjacent to a posterior fractured rib (series 2, image 66) that is present\n within the adjacent soft tissues. The liver, pancreas, spleen, and kidneys\n enhance homogeneously. There is a 9- mm hypodense lesion at the interpolar\n region of the right kidney, too small to characterize, it probably represents\n a cyst. There is no intra-abdominal free fluid. Bowel is grossly\n unremarkable. There are multiple small mesenteric and retroperitoneal lymph\n nodes that do not meet CT criteria for pathologic enlargement. Abdominal aorta\n and vessels appear intact.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a small focus of air within the\n bladder, presumably secondary to Foley catheterization. The rectum and\n sigmoid colon are unremarkable. There is no pelvic free fluid.\n\n BONE WINDOWS: There is a complex comminuted fracture of the left scapula that\n does not appear to extend to the glenohumeral joint. There are fractures of\n the right seventh through twelfth ribs posteriorly, and the right fourth\n through seventh ribs anteriorly. There is a left fourth rib fracture\n posterolaterally. There are left transverse process fractures involving T6\n through T11 and L1 through L4. There is a fracture of the right\n posteroinferior portion of L4 vertebral body. There is a fracture of the L1\n vertebral body involving the superior end plate without retropulsion. There is\n a fracture of the T9 vertebral body superolaterally without retropulsion.\n There are fractures of the inferior pubic rami bilaterally with 6 mm of\n displacement between the left inferior ramus fracture fragments. There is a\n fracture of the left superior pubic ramus and a probable non- displaced\n fracture of the right superior pubic ramus. The alignment of the thoracic and\n lumbar spines is normal.\n\n IMPRESSION:\n 1. Posterior right rib fractures of the seventh through twelfth rib, and\n fourth through seventh rib on the right anteriorly.\n 2. Comminuted left scapular fracture without extension to the glenohumeral\n joint.\n 3. Left transverse process fractures at T6 through T11 and L1 through L4.\n 4. T9, L1 and L4 vertebral body fractures without retropulsion.\n 7. Bilateral inferior pubic ramus fractures and bilateral superior ramus\n fractures.\n 8. Multiple small foci of intrapleural air on the right consistent with tiny\n pneumothoraces.\n 9. Several small foci adjacent to rib fractures low in the abdomen likely\n located in the soft tissues, rather than the peritoneal space.\n 10. Posterior opacities in the lower lobes bilaterally and upper lobes are\n present and may represent atelectasis and/or consolidation, with early\n contusion a possibility.\n 11. Hypodense right renal lesion, too small to characterize.\n (Over)\n\n 10:02 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: +loc, was in a motorocycle accident. known rib, scapula and\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n 12. Mild stranding of the mediastinal fat with multiple small lymph nodes,\n significance of which is uncertain, however, the aorta and great vessels\n appear intact.\n\n The above was communicated to the trauma team including Dr. \n after the completion of the study.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 961835, "text": " 10:37 PM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: abrasion + tender. +loc, was in a motorocycle accident. know\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with\n REASON FOR THIS EXAMINATION:\n abrasion + tender. +loc, was in a motorocycle accident. known rib, scapula and\n spinal fractures,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abrasion, tender. Motorcycle accident.\n\n COMPARISON: None.\n\n THREE VIEWS OF THE LEFT HAND: There is a 1.1 cm linear radiopaque focus that\n appears to project over the soft tissues of the thenar eminence that may\n represent a radiopaque foreign body. This appears to be present on two views.\n No fracture is identified. The alignment is normal. The joint spaces are\n preserved.\n\n IMPRESSION: An 11-mm linear radiopaque focus projecting over the soft tissues\n of the thenar eminence that may represent a radiopaque foreign body. Recommend\n correlation with clinical exam.\n\n" }, { "category": "Radiology", "chartdate": "2155-04-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961857, "text": " 6:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: MULTIPLE RIB FXS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 0634 HOURS.\n\n HISTORY: None provided.\n\n COMPARISON: None.\n\n FINDINGS: Positioning limits the evaluation as the lateral aspects of the\n lower left lung are excluded from view. Again seen is a displaced fracture of\n the superior medial aspect of the left scapula. There is also a displaced\n fracture of the posterolateral left fourth rib. An intercostal hematoma is\n noted over the cupula of the lung. In addition, there is an asymmetry of the\n profile of the T9 vertebral body, known compression fracture. Deformity again\n is evident of the mid diaphysis of the left clavicle. Otherwise the lungs\n remain relatively clear. The mediastinum demonstrates a tortuous aorta but\n otherwise no suspicion for aortic injury. The cardiac silhouette is within\n normal limits for size.\n\n IMPRESSION: Various osseous injuries as previously documented on CT\n examination. No acute interval change. Please note the left costophrenic\n angle is excluded from view.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961973, "text": " 9:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: folow up pntx\n Admitting Diagnosis: MULTIPLE RIB FXS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with\n\n REASON FOR THIS EXAMINATION:\n folow up pntx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST \n\n INDICATION: Pneumothorax.\n\n Cardiac and mediastinal contour are unchanged in appearance. Worsening right\n basilar lung opacity with adjacent increasing right pleural effusion.\n Multiple rib fractures are noted bilaterally. Known spinal fractures are\n better demonstrated on recent CT torso of . Healed right\n clavicular fracture incidentally noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 961828, "text": " 9:48 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n TRAUMA CHEST: There are hazy bilateral upper lobe lung opacities suspicious\n for contusions. There is a minimally displaced posterior left 3rd rib\n fracture. There is a left comminuted scapular body fracture medially. There\n is a lateral wedging of the 9th thoracic vertebral body suspicious for\n compression fracture.\n\n TRAUMA PELVIS: There are nearly nondisplaced bilateral superior and inferior\n pubic rami fractures. There is contrast within the bladder. The femoral heads\n appear normally seated within the acetabulae bilaterally.\n\n Please also refer to the trauma torso CT scan that was obtained later the same\n day for further details.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 961831, "text": " 10:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: MOTORCYCLE ACCIDENT. PAIN.R/O BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with\n REASON FOR THIS EXAMINATION:\n +loc, was in a motorocycle accident. known rib, scapula and spinal fractures,\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SAT 11:04 PM\n no acute bleed identified.\n slightly prominent lateral ventricles, no midline shift.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle accident, rule out bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of acute intra- or extra-axial hemorrhage.\n There is slight prominence of the lateral ventricles, with no previous studies\n available for comparison to determine chronicity. No fracture is identified.\n Visualized portions of the paranasal sinuses are clear.\n\n IMPRESSION:\n 1. No evidence of acute intracranial hemorrhage.\n 2. Slight prominence of the lateral ventricles bilaterally, no previous\n studies are available for comparison to determine chronicity.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "L ANKLE (AP, MORTISE & LAT) LEFT", "row_id": 961836, "text": " 10:37 PM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with s/p mvc and L ankle abrasion and edema\n REASON FOR THIS EXAMINATION:\n ?fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ankle abrasion and edema, ? fracture.\n\n COMPARISON: None.\n\n THREE VIEWS OF THE LEFT ANKLE: The ankle mortise is congruent with the talar\n dome. There is slight soft tissue swelling overlying the lateral malleolus.\n No fracture is identified. Joint spaces are preserved.\n\n IMPRESSION: Mild soft tissue swelling, no fracture identified.\n\n\n" }, { "category": "ECG", "chartdate": "2155-04-12 00:00:00.000", "description": "Report", "row_id": 225069, "text": "Baseline artifact. Sinus tachycardia. Low limb lead voltage. Possible\nQRS alternans. Clinical correlation is suggested. (Question pericardial\neffusion). No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-04-13 00:00:00.000", "description": "Report", "row_id": 1416571, "text": "TSICU Admit Note 1900-0700\n 42yo male on motorcycle, rearended a car, unknown rate of speed.?LOC at scene, brought to Hospital, found to have mult spinal and rib fx, no intercranial bleeding. transferred by EMS to for further eval/treatment.\n Injuries include: fx of L scapula body,? fx of R scapula. Fx L 4th rib, R ant 4-6th ribs, R post ribs, L tranverse process fx C5, T6-9, L1-2, and fx of body of T9.\n Pt has NKA, denies PMH except R knee tendon surgery for old athletic injury, occ Percocet for knee pain. No other meds. Smokes 1ppd, occ marijuana use, beer on weekends, denies hx ETOH w/drawal.\n Review of Systems\nNeuro- alert, oriented to hospital but not specific hospital,moves all extrems on command.Perserevates occ, asking for water, non-compliant w/spinal precs. Freq reminders of rationale for logroll,reverse tberg.\nPt more compliant when more comfortable. PCA started, activated by nursing as needed\n CV- MP SR,no VEA. BP stable, IVF at 125/hr.Peripheral lines x2 R and L 16 guage.Pulses+, boots in place, SQ Heparin started.\n Resp- +smoker w/mult rib fx. IS started, pt initially 500cc, then unable to continue d/t pain,refuses further IS.LS diminished bilat,\nenc to use Dilaudid PCA .consult to pain service by resident, ? epidural placement today.CXR done, results pending\n GI- abd soft, hypo bs. Freq mouth care, pt complains persistently of thirst\n GU u/o qs by Foley, Urojet x1 for bladder spasms\n Skin- mult abrasions, \"road rash\"- see carevue\n Social- is spokesperson, pt lives w/her intermittently. Pt questions whether rib fx could be old, from recent altercation w/. Pt is divorced, has children\n Plan-\n pain control\n pulmonary toileting\n advance act as per team\n ? advance diet for comfort\n" }, { "category": "Nursing/other", "chartdate": "2155-04-13 00:00:00.000", "description": "Report", "row_id": 1416572, "text": "NPN 7a-7p\n\nrevised list of injuries:\n\nposterior right rib fx \nanterior right rib fx \ncomminuted left scapular fx\nleft transverse process fx T6-T11 and L1-L4\ninferior lateral L4 vertebral body fx\nanterio-lateral T9 vertebral body fx\nbilat inferior pubic rami fx\nLeft superior pubic rami fx\nright right intraplural air- tiny pnumothoraces\n\n\n\nneuro- pt alert and cooperative with significant short term memory deficit. pt does not know the date (month/day) consistantly. does occasionally know the place, and is always oriented to person. pt knows reason for hospitalization but does not remember the accident. MAE = grasps. unable to lift left arm due to scapular fx, unable to straighten legs and lift knees due to pubic rami fx. + sensation through out. cont on dilaudid PCA .25 every 6min. with some pain. pain still cont to restrict movement. toradol added prn by MD. APS in to see pt about possible epidural pt refused at this time. TLS cleared by spine service. c-spine no fx on CT however pt does c/o neck pain. MRI ordered to check for ligiment injury. check list sent, MRI does not have a time for pt to be scanned yet.\n\nCV- NSr rate 60-80's. sbp- 130-140. + peripheral pulses, Sq heparin and p-boots.\n\nresp- lung sounds clear and diminished in bases. O2 at 2liters NC. satting 95-100%. taking shallow breaths on own but encouraged to take deep breaths and cough. encouraged to use IS. CXR from this am- no acute change.\n\nGI- diet advanced only to sips due to L4 fx and relatonship/ possiblity of illeus. pt taking sips well. + n/v x2 vommitted 30cc clear liquid. zofran given X2. + BS abd soft, no flatus or stool. pepcid for prophalxis\n\nGU- foley clear yellow urine, good amt. mag replaced this am. LR 125/hr\n\nskin- numerous abrasions from accident. dsd intact to left hand, left hip and left foot.\n\nID afebrile.\n\northo- PT/OT to see pt. pt does not require surgery or a brace from ortho perspective. TLS cleared by spine service. splint placed to left arm for immobilization of left shoulder. pt may full weight bear bilat LE with pubic rami fx per ortho. no left ankle fx no left hand fx.\n\nsocial- spoke with pt fiance this afternoon due to pt confusion and inability to clearly make decisions fiance will contact patients for info and needed consents. social services aware of pt situation and worries about inability to work. social work will see pt on mon.\n\nplan- MRI to eval c-spine. cont good pulm toilet. assess for on going need for epidual. cont pain control.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-04-14 00:00:00.000", "description": "Report", "row_id": 1416573, "text": "TSICU Progress Note 1900-0700\n To MRI overnight for assessment of ligament damage, Cspine precs maintained\n Review of Systems\n Neuro- Cont w/short term memory probs, but sl. better.MAE,able to shift himself around in bedto make himself more comf. Using Dilaudid PCA w/enc,also med w/Toradolx1 w/effect, Dilaudid 2mg iv x2 for breakthrough pain, and for trip to MRI, w/ gd effect.Pain is primarily in L shoulder, R chest and L knee(old ligament injury)\n CV-MP SR, no VEA.BP stable.Peripheral lines x2 intact, IVF now at 75/hr L foot sl. edematous, pulses equal bilaterally\n Resp- NC 2lpm, LS diminished at bases.Improved IS to 750cc, c+r tick pale sputumx1.\n GI- sips h2o, bs+,abd soft. Nausea upon transfer to MRI, subsided w/ deep breathing/relaxation.\n GU- u/o qs\n Skin- abrasions open to air, sm abrasion behind L ear cleaned w/ H202\n Plan\n Continue pain management\n Continue pulmonary toileting\n Clear Cspine\n Advance act as able\n" } ]

[ { "category": "Radiology", "chartdate": "2142-12-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 988780, "text": " 6:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal- will be\n Admitting Diagnosis: MITRAL REGURGITATION\\MITRAL VALVE REPLACEMENT,HEART PORT MINIMALLY INVASIVE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal- will be in CVICU approx.\n 5:30 PM\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:19 P.M. ON \n\n HISTORY: MVR.\n\n IMPRESSION: AP chest compared to preoperative films on :\n\n Tip of the endotracheal tube above the upper margin of the clavicles with the\n chin elevated is at least 7 cm from the carina and approximately 2 cm above\n optimal placement. Swan-Ganz catheter, right pleural and midline drains are\n in standard placements, but the nasogastric tube ends at the gastroesophageal\n junction and will need to be advanced at least 10 cm to move all the side\n ports into the stomach. There could be some anterior pneumothorax on the left\n on the supine view. Pneumomediastinum is present, a common postoperative\n finding. A subsequent radiograph should be performed with the patient erect\n if feasible.\n\n These findings were discussed with a member of the cardiothoracic care team\n over the telphone, at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 988866, "text": " 11:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal ? ptx\n Admitting Diagnosis: MITRAL REGURGITATION\\MITRAL VALVE REPLACEMENT,HEART PORT MINIMALLY INVASIVE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p mvr\n REASON FOR THIS EXAMINATION:\n s/p ct removal ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mitral valve replacement; chest tube removal, to assess for\n pneumothorax.\n\n FINDINGS: In comparison with the study of , the chest tube has been\n removed and there is no pneumothorax. Various other tubes have also been\n removed. Some residual atelectatic changes are seen at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-12-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 989205, "text": " 9:16 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: MITRAL REGURGITATION\\MITRAL VALVE REPLACEMENT,HEART PORT MINIMALLY INVASIVE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p mvr\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male status post mitral valve replacement. Evaluate for\n infection, effusion.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Retrosternal gas and a small air-fluid level are seen\n on the lateral view, probably related to recent sternotomy. The left basilar\n atelectasis has improved. However, there is a persistent small left pleural\n effusion. There is also a probable small right pleural effusion. The lung\n fields are clear. Cardiomediastinal contours are normal. Sternotomy wires\n and artificial mitral valve are unchanged.\n\n IMPRESSION:\n 1. Retrosternal gas and air-fluid level, probably related to recent\n sternotomy.\n 2. Persistent small left pleural effusion and probable small right pleural\n effusion.\n\n" }, { "category": "Echo", "chartdate": "2142-12-27 00:00:00.000", "description": "Report", "row_id": 60081, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Mitral valve prolapse. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 16:01\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color Doppler or saline\ncontrast with maneuvers.\n\nLEFT VENTRICLE: Moderately dilated LV cavity. [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.]\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). Mild to moderate\n(+) AR. Eccentric AR jet directed toward the anterior mitral leaflet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate/severe MVP.\nSevere (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPRE BYPASS\nNo atrial septal defect or patent foramen ovale is seen by 2D, color Doppler\nor saline contrast with maneuvers. The left ventricular cavity is moderately\ndilated. [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.] Right ventricular\nchamber size and free wall motion are normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque. The aortic valve leaflets (3) are mildly thickened. Mild to moderate\n(+) aortic regurgitation is seen. The aortic regurgitation jet is\neccentric, directed toward the anterior mitral leaflet. The mitral valve\nleaflets are mildly thickened. The posterior MV leaflet is markedy\nredundantant. A torn chordae is visualized attached to the posterior leaflet.\nThere is moderate/severe mitral valve prolapse. Severe (4+) mitral\nregurgitation is seen. There are two distinct MR jets, one which is\nposteriorly directed.\n\nPOST BYPASS\nLV systolic function is mildly globally hypokinetic. LVEF~ 45%. There is a\nwelol seated well functioning bileaflet mechanical valve in the mitral\nposition. MR is present which is normal in quantity and location for this type\nof prosthesis (washing jets). The study is otherwise unchanged from prebypass.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-12-28 00:00:00.000", "description": "Report", "row_id": 1619449, "text": "NEURO- AWOKE WHILE ON LOW DOSE PROPOFOL.SEMI-ABLE TO FOLLOW COMMANDS.ICU ENVIRORMENT/POST-OP PLAN OF CARE EXPLAINED. REVERSALS & PAIN MEDICATION GIVEN. DOZING OFF/ON. PT COMPLIANT WITH CARE & ABLE TO FOLLOW ALL COMMANDS WHEN FULL AWAKE. VOICES NEEDS AND CONCERNS ABOUT SURGERY. EXPLANATIONS/SUPPORT GIVEN.\n\nCV- NSR 80-90 WITH PVC'S. K+/CA+/MG REPLETED PRN. FILLING PRESSURES LOW WITH HYPERDYNAMIC CO.FLUID RESUSITATED WITH 3L LR.SKIN W-D-I. PALP PULSES.\n\nRESP- WEANING PROTOCOL FOLLOWED. PT @ 2350 TO 5LNC. SATS=99%. O2 WEANED TO 2LNC. LSC APICES,DIM BASES. SMALL AMT SANG/DRG FROM CT. I.S TEACHING COMPLETE.\n\nGI- ABD SOFT. ABSENT BS. TAKING ICE CHIPS.\n\nGU- AUTO DIURESING > 150CC/HR.\n\nPAIN- MEDICATED WITH 4MG IVP MS04 Q2-3H WITH EFFECT.\n\nPLAN- DE-LINE. INCREASE DIET & ACTIVITY AS TOLERATED. START LOPRESSOR. PAIN MANAGEMENT. TRANSFER TO TODAY.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-12-28 00:00:00.000", "description": "Report", "row_id": 1619448, "text": "Respiratory Care:\nPatient extubated at Appx. 2345 and placed on N/C.\n" }, { "category": "ECG", "chartdate": "2142-12-27 00:00:00.000", "description": "Report", "row_id": 109095, "text": "Sinus rhythm. Premature ventricular beats. Left ventricular hypertrophy with\nsecondary ST-T wave changes. Non-diagnostic inferior Q waves with T wave\ninversions of uncertain significance. Clinical correlation is suggested.\nCompared to tracing of the period of ectopic atrial rhythm is absent.\nVentricular rate is faster.\n\n" } ]

[ { "category": "Echo", "chartdate": "2177-12-01 00:00:00.000", "description": "Report", "row_id": 78409, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 160\nBSA (m2): 1.92 m2\nBP (mm Hg): 109/69\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:30\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 cavity size. Moderate regional LV systolic\ndysfunction. Moderately depressed LVEF.\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.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity size is normal. There is moderate regional left\nventricular systolic dysfunction. Overall left ventricular systolic function\nis moderately depressed.\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n4. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-04 00:00:00.000", "description": "RENAL U.S.", "row_id": 844871, "text": " 9:03 AM\n RENAL U.S. Clip # \n Reason: asses renal size. ?atrophy\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with acute on chronic renal failure.\n REASON FOR THIS EXAMINATION:\n asses renal size. ?atrophy\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND:\n\n INDICATION: Acute and chronic renal failure.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 12.3 cm in length. The left kidney\n measures 11.8 cm in length. No stones or hydronephrosis is seen. The renal\n cortex is slightly thinned bilaterally. There are innumerable bilateral renal\n cysts, most likely simple. No free fluid is seen.\n\n IMPRESSION: Multiple bilateral renal cysts, likely simple. No\n hydronephrosis or stones.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845652, "text": " 9:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening CHF, ? worsening effusions\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and renal failure. Requiring more O2\n\n REASON FOR THIS EXAMINATION:\n ? worsening CHF, ? worsening effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of MI renal failure and congestive heart failure\n requiring more oxygen. COMPARISON: Radiograph dated \n\n AP PORTABLE UPRIGHT VIEW OF THE CHEST: Again demonstrated are bilateral\n pleural effusions with bibasilar consolidation/collapse. Again noted is a\n right vague apical nodular density, unchanged. The borders of the heart are\n obscured. No evidence of pneumothorax. The mediastinal contour is stable.\n\n IMPRESSION: No significant change compared to the study of .\n\n" }, { "category": "Radiology", "chartdate": "2177-12-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845519, "text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change of CHF, ?infiltrate\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and low grade fever. Requiring more O2\n\n REASON FOR THIS EXAMINATION:\n assess for interval change of CHF, ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acue MI, CHF, low grade fever.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Made with prior chest radiograph dated .\n\n FINDINGS: Again note is made of mild cardiomegaly. The mediastinal and hilar\n contours are unchanged compared to the previous study. Again note is made of\n bilateral pleural effusion, with bibasilar atelectasis. Note is made of\n increased pulmonary vasculature with increased interstitial markings,\n representing congestive heart failure, which is unchanged compared to the\n previous study. Note is made of nodular opacity in the right apex, measuring\n approximately 1 cm, which needs further evaluation by CT scan.\n\n IMPRESSION: Moderate cardiomegaly, CHF, bilateral pleural effusion and\n atelectasis. Nodular opacity in the right apex, please evaluate by chest CT.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845723, "text": " 8:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p thoracentesis on the R. Please evaluate for lung reexpan\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and renal failure. Requiring more O2\n\n REASON FOR THIS EXAMINATION:\n s/p thoracentesis on the R. Please evaluate for lung reexpansion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 79 year old male with acute myocardial infarction and\n hypoxia.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: Examination performed ten hours prior.\n\n FINDINGS: As before, there is cardiomegaly. The aorta is unfolded. There is\n upper zone redistribution of the pulmonary vasculature and perivascular haze,\n consistent with congestive failure. There is a small left pleural effusion\n with associated collapse/consolidation of the left lower lobe. A very small\n right pleural effusion persists. The osseous structures are unremarkable.\n\n IMPRESSION: Congestive heart failure pattern as above. Small left pleural\n effusion with compressive atelectatic changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844436, "text": " 12:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening CHF vs pneumonia\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and low grade fever.\n\n REASON FOR THIS EXAMINATION:\n ? worsening CHF vs pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute MI, CHF, low-grade fever.\n\n COMPARISON: One day previously.\n\n SINGLE VIEW CHEST, AP: Of note, this image is being dictated on as the image was initially lost on PACS. There are again bilateral\n pleural effusions and increased interstitial opacities in the perihilar,\n predominantly basilar distribution. These appear improved when compared to\n the previous study. There is a left ventricular configuration to the heart.\n\n IMPRESSION: Improving left ventricular heart failure. Bilateral pleural\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845823, "text": " 4:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p thoracentesis- evaluate for lung expansion\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and renal failure. Requiring more O2\n\n REASON FOR THIS EXAMINATION:\n s/p thoracentesis- evaluate for lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute myocardial infarction, CHF and renal failure. Increasing\n 02 requirement. Status post thoracentesis. Evaluate pulmonary expansion.\n\n COMPARISON: .\n\n The heart size is unchanged. Pulmonary vascular redistribution remains\n similar in appearance. The left pleural effusion has decreased in size. Both\n costophrenic angles remain blunted, compatible with persistent small bilateral\n pleural effusions. Aeration of the left lung has increased, and mild\n atelectasis in the left lung base is now more apparent. No pneumothorax is\n detected.\n\n IMPRESSION: Decreased left pleural effusion with corresponding increase in\n left pulmonary expansion. Mild left basilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2177-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844322, "text": " 2:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute coronary syndrome.\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute coronary syndrome.\n\n VIEWS: Portable upright frontal radiograph.\n\n COMPARISON: No prior studies.\n\n FINDINGS The heart appears normal in size. The aorta is slightly tortuous.\n There are bilateral perihilar and lower lobe hazy infiltrates with septal\n lines evident. There is slight upper zone redistribution of the pulmonary\n vasculature. There appears to be a small right pleural effusion. The left\n costophrenic angle is excluded from this study. There is no pneumothorax. A\n thin linear radiodensity is seen overlying the 3rd right posterior rib, of\n uncertain etiology, possibly extrinsic to the patient.\n\n IMPRESSION: Multifocal interstitial and alveolar opacities, presumably\n related to edema (given history) and less likely due to multifocal infection.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844621, "text": " 7:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess volume status\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and low grade fever. Requiring more O2\n\n REASON FOR THIS EXAMINATION:\n assess volume status\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest .\n\n INDICATION: Low grade fever.\n\n Comparison is made to previous study of one day earlier.\n\n The cardiac and mediastinal contour are stable. The pulmonary vascularity\n appears engorged centrally but there is attenuation of the upper lobe\n vasculature consistent with underlying emphysema. Multifocal alveolar\n opacities are noted in the perihilar and basilar regions, somewhat asymmetric,\n remaining worse on the right than the left. There is a moderate to large\n right pleural effusion and a small left pleural effusion, which are unchanged.\n Overall, allowing for differences in technique, there has been slight\n worsening opacity in the right perihilar region, but otherwise no significant\n change.\n\n IMPRESSION: Persistent perihilar opacities with slight worsening in right\n perihilar region. These findings may be due to asymmetrical CHF superimposed\n emphysema, but aspiration pneumonia is within the radiological differential\n diagnosis.\n\n Bilateral pleural effusions, right greater than left.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844487, "text": " 1:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusions\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute MI, CHF, and low grade fever. Requiring more O2\n\n REASON FOR THIS EXAMINATION:\n r/o effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute MI, low-grade fever, hypoxia.\n\n COMPARISON: One day previously.\n\n SINGLE VIEW CHEST, AP ERECT: There are again bilateral perihilar interstitial\n opacities with a lower lobe predominance. There are also bilateral pleural\n effusions which do not appear significantly changed from the previous study,\n allowing for technique. There is bibasilar atelectasis. The aorta is\n slightly unfolded with wall calcifications and there is a mild dextroscoliosis\n of the thoracic spine.\n\n IMPRESSION: Persistent perihilar interstitial opacities and bilateral pleural\n effusions consistent with left ventricular heart failure.\n\n\n" }, { "category": "ECG", "chartdate": "2177-12-06 00:00:00.000", "description": "Report", "row_id": 181836, "text": "Atrial fibrillation. Left ventricular hypertrophy with secondary repolarization\nabnormality. Extensive ST-T wave changes are due to either left ventricular\nhypertrophy or myocardial ischenia. Low QRS voltage in the limb leads. Since\nthe previous tracing of atrial fibrillation is new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-12-03 00:00:00.000", "description": "Report", "row_id": 181837, "text": "Sinus rhythm. Since the previous tracing of the patient is again in a\nsinus rhythm. The rate is slower and an occasional atrial premature beat is\nnoted. There is otherwise, no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2177-12-01 00:00:00.000", "description": "Report", "row_id": 181840, "text": "Sinus rhythm, rate 88. Since tracing #1, the patient has converted to sinus\nrhythm. No other significant changes are seen.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2177-12-01 00:00:00.000", "description": "Report", "row_id": 181841, "text": "Atrial fibrillation with an average ventricular response, rate 107. Since the\nprevious tracing of positional changes are noted over the lateral\nprecordium.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-11-30 00:00:00.000", "description": "Report", "row_id": 181842, "text": "The rhythm appears to be an atrial flutter/fibrillation, rate 102. Since the\nprevious tracing of there is more regularity to the rhythm at present.\nPositional changes are seen over the lateral precordium.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-11-30 00:00:00.000", "description": "Report", "row_id": 181843, "text": "Atrial fibrillation with rapid ventricular response.\nExtensive ST-T changes may be due to myocardial ischemia or infarction\nSince previous tracing of , the rhythm is now atrial fibrillation\n\n" }, { "category": "ECG", "chartdate": "2177-11-29 00:00:00.000", "description": "Report", "row_id": 181844, "text": "Sinus rhythm\nSupraventricular extrasystoles\nBorderline first degree A-V block\nLeft atrial abnormality\nLeft axis deviation\nOld inferior infarct\nMarked ST depression in V lead, consider recent infarction\nAnterolateral ST-T changes suggest myocardial injury/ischemia\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2177-11-29 00:00:00.000", "description": "Report", "row_id": 181845, "text": "Atrial fibrillation\nPossible inferior infarct - age undetermined\nAnterolateral ST-T changes may be due to myocardial ischemia or infarction\nRepolarization changes may be partly due to rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2177-12-02 00:00:00.000", "description": "Report", "row_id": 181838, "text": "Atrial fibrillation with rapid ventricular response\nPossible inferior infarct - age undetermined\nAnterolateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince previous tracing of , the rhythm is now atrial fibrillation\n\n" }, { "category": "ECG", "chartdate": "2177-12-01 00:00:00.000", "description": "Report", "row_id": 181839, "text": "Sinus rhythm with PACs with borderline 1st degree A-V block.\nLeft atrial abnormality\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of , anterolateral ST-T wave abnormalities are\nmore marked\n\n" }, { "category": "ECG", "chartdate": "2177-12-11 00:00:00.000", "description": "Report", "row_id": 185279, "text": "Atrial fibrillation. Inferior/lateral St-T wave changes may be due to ischemia.\nCompared to the previous tracing the atrial fibrillation is faster.\n\n\n" }, { "category": "ECG", "chartdate": "2177-12-08 00:00:00.000", "description": "Report", "row_id": 185280, "text": "Junctional rhythm\nInferior/lateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing, junctional rhythm is new\n\n" }, { "category": "ECG", "chartdate": "2177-12-07 00:00:00.000", "description": "Report", "row_id": 185281, "text": "Sinus rhythm. Possible anterior myocardial infarction - age undetermined.\nInferior/lateral ST-T wave changes suggest myocardial injury/ischemia. Since\nthe previous tracing atrial fibrillation is resolved and lateral ST-T wave\nchanges are less prominent.\nTRACING #2\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-04 00:00:00.000", "description": "Report", "row_id": 1425065, "text": "CCU NPN 1900-0700\nS: \" I can't sleep \"\nO: c/o trouble sleeping. given additional 25mg trazadone po with good effect.\n\nCV: HR 87-93AFib. no VEA. BP 89-102/40-50's. contin. on natrecor initially at .01mcq/k/min. u/o only 15-30cc/hr. 2130: given bolus 1mcq/k and increased gtt to .015mcq/k/min. no responce seen to inc. natrecor dose. lasix 40mg IV x1 at MN. still only 15-30cc/hr x2hours - then u/o incresed to 100-200cc x2hours. (+) 300cc for . currently neg 200cc.\n\nfoley was irrigated/flushed x2 in eve for small amt. of blood clot/tissue with improved flow. urine clear. no sed.\n\nresp: LS crackles bases. sats improved to 99% on NRB. placed on 100% cool neb for couple hours in eve with good sats. however, pt. stating he felt breathing better on NRB. placed back on. sats drop to 94% when sleeping.\n\nGI: trying to restrict liquids. asking for water. no stool.\nrenal: renal consult - contin. natrecor gtt.\n\nA: worsening renal function with CHF.\n improved u/o with natrecor/lasix.\nP: follow lytes, cr, HCT. follow plan for diuresis. renal following.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-04 00:00:00.000", "description": "Report", "row_id": 1425066, "text": "NURSING PROGRESS NOTE 7A-7P\n\nS: My breathing feels ok today.\n\nO: please refer to carevue for vs and trends.\n\nNEURO: Alert and oriented x3. Cooperative with care. OOB to chair for ~2 hrs. TOlerated well. Evaluated by PT today with recommendation for increasing ambulation as tolerated.\n\nRESP: LS with bibasilar rales; slightly diminished at right base.\nWearing 100% NRB most of day. Was able to tolerate 6L NC with sats ~90-91 during meals.\n\nCARDIAC: HR 80's afib. No ectopy noted. BP 88-100/50's. Rec'd lopressor 12.5 mg X1 today (parameters changed to hold for SBP < 90). Conts on Natrecor gtt at .015mcg/kg/min.\nNo plans to cath as of yet given increased INR (3.2) and worsening RF.\n\nGI: abd soft NT. +BS. no stool this shift. Eating only small amt food throughout day (more thirsty than hungry). HCT 28 this morning-> rec'd 1Unit PRBCs. Repeat HCT 30.1. No s/s active bleeding.\n\nGU: foley draining clear yellow urine. Pt is +29cc this evening. Rec'd additional dose of 80mg IV lasix this afternoon-> will cont to assess effect. BUN 109/ CREAT 3.9. Renal consulting for potential HD and ultrafiltration tomorrow.\n\nID:Afebrile.\n\nA: 76 y.o. male with ARF in setting of recent GIB and MI.\n\nP: Per interdisciplinary team, plan for HD and UF tomorrow if creat conts to rise. Cont natrecor. Aiming for ~500cc negative by midnight.\nFollow HCT closely. Assess for s/s acute bleeding.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-02 00:00:00.000", "description": "Report", "row_id": 1425061, "text": "CCU Nursing Progress Note\nS: I feel fine\n\nO: Despite tachypnea and HR conversion to AF, pt is subjectively asymptomatic\n\nHR initially 110-110 SR/ST with freq APC's. Rx with Lopressor 2.5 with subsequent decrease in HR to 90's. BP stable 119/64 down to 94/62 post lopressor. At 0130, Pt had rec'd 2.5 lopressor for increased HR 120-130 with BP down to 94/63 after dose. Pt then converted into afib. Rate variable 120-140 with BP 95-104/55-70. ECG done. Pt again is asymptomatic. Fellow notified by house staff, and Digoxin .5mg po given per order at 0410.\nCPK's have not decreased yet, as 10pm cpk 371/MB 70.\n\nResp - Pt on 100% NRB through night and is tachypnic rate 22-29. Pt denies SOB. Ls have faint BBRales and are diminished 1/2up. O2 sats are 93-99%.\n\nGI/ Heme- Passed one Melana stool, approx 150cc loose stool. Hct at 10pm was increased to 32.3 (Previous 28.7 pre i Unit PRBC's).\n\nGU - Foley clear yellow urine, but at times is clear, light pink. u/o 180cc/hr post Lasix from 6pm. By 1am, u/o down to 100cc/hr. Pt denies sob. Examined by house staff. Lasix 40mg IV x1 at 0115. u/o 150-180cc/hr post.\n\nSocial - Daughter and son in early evening and are aware of plan.\n\nA: Irregular HR, starting dig load. Asymptomatic despite increased HR and conversion to afib. Hct stable initially after PC.\n\nP: Cont close monitoring on CV status, and continue dig load with doses at 1230pm and 2330pm. Continue monitor resp status closely. Attempt to decrease O2 requirement as able. Check freq Hcts and monitor stools. Keep pt and family informed of status/ situation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-02 00:00:00.000", "description": "Report", "row_id": 1425062, "text": "CCU NPN 7a-7p\nS: \"I feel alright...my breathing feels better.\"\n\nO: Please see flowsheet for additional data. Pt is 79 y/o male with PMH of COPD, CAD, CVA, liver failure, CRI, MI, PVD, sz, afib, smoker (quit approx 15 yrs ago). Pt came to OSH with CP, EKG showed ST depressions V4-V6, LS revealed crackles on exam, afib. Pt started on heparin. Pt transferred to , given Heparin, integrillin, reapro, plan to cardiac cath on , but INR 2.7 and elevated BUN/Creat. Pt had guiac + stool with melena, HCt dropped, pt received 1 unit PRBC's. Enzymes were trending down but began increasing. Pt transferred to CCU on for closer monitoring with NSTEMI, GIB and CHF. ECHO from EF 35%, MR 2+, TR2+.\n\nCV: Pt HR 97-130 afib, BP 94-123/55-84. Pt was started on Lopressor 5 mg IV Q6H for rate control. HR was still in 100's-120's so amiodarone was started at approx 1415. Amiodarone bolus given and gtt started, BP tol. Pt denies CP. Pulses dopplerable this am, palpable this afternoon. Pt extremities are warm, bruising from apparent IV insertion attempts throughout arms. CPKs trending up, 371 to 652, to 529 this afternoon. Hct 30.4 (30.7 this am). K 3.6, repleted with 20 meQ of KCL at 1700. Mg 2.0. Pt INR 2.4 this am, 2.3 this afternoon.\n\nResp: Pt RR regular/tachy. Pt has minimal c/o occ SOB. Pt on nonrebreather 100%. Attempted to wean pt to NC, pt O2 sats dropped to 85, pt put back on nonrebreather. LS fine crackles at bases, at times diminished. Pt has dry cough.\n\nGI/GU: Pt has foley cath craining clr yellow urine, approx 45-140 cc/hr. Pt denies abd pain, no stool this shift. Pt abd soft, bs x 4, NPO except for clr liquids with meds. Pt had some c/o nausea, Promethazine 12.5 mg IV given with good effect. Pt coughed up/vomited x2, scant amt of tan colored fluid. BUN 103 (was 97), creatinine 3.2 (was 2.9).\n\nNeuro: Pt A&O x 3, pt MAE, cooperative and follows commands.\n\nSocial: Pt daughter called x2 today and spoke with RN regarding POC. Daughter was updated on pt condition.\n\nA/P: 79 y/o male with increased BUN/creat and increased INR to await cardiac cath. Amiodarone gtt started and Lopressor IV for rate control. Pt continues to put adequate amts of urine. Per rounds, possibly start Natrecor if BP will tol and u/o decreases. Pt with no active bleeding this shift, but no stool this shift. Pt denies abd pain. Pt with minimal c/o occ SOB, some c/o nausea. Continue to monitor hemodynamics and follow up with Team regarding natrecor and u/o. Monitor electrolytes and replete as necessary. Continue to monitor for GIB. Continue to monitor resp status and continue to provide support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-03 00:00:00.000", "description": "Report", "row_id": 1425063, "text": "CCU NPN 1900-0700\nS: \" I feel about the same \"\nO: reporting no significant change from yest. breathing about the same.\npt. able to tolerate cool neb at 100% for a few hours with sats 95%. however, when asleep, sats dropping to 92% and placed back on NRB for remainder of night. LS crackles at bases. sats 95-97% on NRB.\nusing inhalers with spacer. dry cough. c/o dry mouth d/t mask. taking sips of water.\n\nCV; HR 100-103Afib . on amio gtt - decreased to .5mg/hr at 2100. started on po lopressor 12.5mg in eve. IV lopressor d/c'd.\nconverted back to NSR ~ 0230. occas. PAC's. HO aware. BP stable.\n91-104/40-50's.\n- discussion weather to start natrecor last eve with high FIO2 requirment and . u/o. decision made not to start d/t borderline SBP<100.\nGU: foley draining 20-50cc/hr. leaking around meatus this AM with med. damp spot on sheets. also drained 160cc x2hr with balloon reinflated. neg. 1.1L for and currently ~ 300neg.\nGI: cl. liqs only . no stool. no nausea. HCT 2300- 27.8 however it was initially reported as 31. error noted this AM. 0600 HCT pnd.\nneuro: A/O x3. no c/o pain/discomfort. MAE. trazadone for sleep with good effect. family visited and left ~ 2100.\n\naccess: PIVx2. one PIV d/c'd d/t leaking.\n\nA: 79yo male with hx CRI, admitted from OSH for cath on reopro and heparin. recent course c/b GI bleed/melena req. 2UPRBC, creatinine elevated to 3.2 (2.9), CPK bump to 500/73 and high FIO2 requirments. not able to cath at this time.\nP: follow HCTs, lytes. monitor HR/rhythm for change. ? titrate lopressor po dose. ? start natrecor. wean FIO2 as able.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-03 00:00:00.000", "description": "Report", "row_id": 1425064, "text": "CCU NPN 7a-7p\nS: \"My breathing feels better.\"\n\nO: Please see flowsheet for additional data. Pt is a 79 y/o male admitted on with NSTEMI, d/t have cath on , but not done c/b GIB and increasing INR, BUN, Creatinine, CRI.\n\nCV: Pt HR 78-88 NSR with no ectopy noted until approx 1530. Pt 92-113/51-66, MAPs 63-77. Amiodarone gtt off at 1500, Amiodarone PO started. Pt started on Natrecor at approx 1630, d/t decreased u/o natrecor bolus 1 mcg/kg given ( normal bolus for weight), natrecor gtt 0.01/mcg/kg/min, pt BP tol. Pt on metoprolol 12.5 mg PO TID for rate control. The dose due at 1600 was held d/t low BP and anticipated start of natrecor. Pt HR increased and converted into afib metoprolol dose given at 1730, BP tol. EKG done, HO aware and ordered additional Metoprolol 12.5 mg PO x 1, BP tol. Pt denies CP. Pulses weak palp. Hct 30.7 (was 28.8), K 3.4, repleted with 20 meq KCL PO.\n\nResp: Pt RR reg/tachy at times, O2 sats 92-97 on nonrebreather 15 L, pt put on NC 5 L for several hours, O2 sats dropped 91-92, pt put back on nonrebreather 10 L. Pt denies SOB, but appears to have increased work of breathing while on NC. LS with crackles at bases.\n\nGU: Pt has foley cath draining clr yellow to dark yellow urine. U/O from approx 10-55cc/hr. This am foley had 10 cc out for one hour, foley irrigated, no clot or obstruction noted. Balloon was deflated and reinflated. Pt BUN 103 (was 104 this am) creat 3.5. Renal consult ordered and renal fellow up to see pt (see note in chart). Urine lytes ordered and sent, urine BUN 972, creat 86, Na 21.\n\nGI: Pt abd soft +BS x 4, no stool this shift. Pt taking PO liquids well, pt tol 1 slice of toast this afternoon. Pt denies nausea and abd pain.\n\nID: Pt afebrile, T max 96.7 orally.\n\nEndo: Pt bld glucose level 154 this afternoon, HO notified, pt ordered to start sliding scale SC insulin.\n\nSocial: Pt daughter called this am, spoke with RN and pt.\n\nA: Pt is 79 y/o NSTEMI awaiting cardiac cath, postponed d/t increased INR, Creat/BUN, continue to med manage. Pt on amio drip and lopressor PO in NSR for most of shift, changed to PO amio, HR converted to afib. Renal fellow in to see pt. Natrecor gtt started and BP tol.\n\nP: As discussed in interdisciplinary rounds, continue to monitor hemodynamics. Continue to monitor cardiac rhythm. Continue with Natrecor as BP tol and to cont to diurese. Cont PO lopressor and amiodarone for rate control. Continue to monitor resp status. Follow up with Renal team regarding ? of dialysis and renal func. Continue to provide emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-01 00:00:00.000", "description": "Report", "row_id": 1425060, "text": "CCU Admission Note\nS: \"Yes, my breathing is hard.\"\n\nO: Please see Admission/FHP for complete details and PMH.\n\nIn brief, pt is a 79y.o. male who presented to OSH on with CP, w/u sshowed ST depressions V4-V6 and CHF on exam, +Enzymes. CP free s/p- SL Nitro and transferred to for future Cath. At , started on Integrillin (later switched to Reapro for kidney function). Enzymes trending down, so medically managed on floor and Cath planned for . In setting of AM INR 2.7 and Renal insufficiency, Cr 2.6 today (up from 2.1 on adm), pt did not go to cath. Pt given 10mg PO Vit K. Hct 28 today slowly trending down over admission , had rcvd 1u PRBCs yesterday. 1u PRBC Transfusion started on floor today and finished after arrival to CCU. Pt with black stool today- GI consulted. Pt also acutely SOB w/o CP, EKG w/o change per floor team. Given Lasix 20mg IV, followed by 40mg IV. Transferred to CCU.\n\nCV: HR 90-100 ST with PACs, hx of a-fib. BP 109-135/60s. MAP 80s. AM lytes: K+3.5 and Mg 1.7 repleted floor RN. No edema. Dopplerable LE pulses. PRBC transfusion completed at 1900. Enzymes trending up as of this am, last CK/MB/Trop 221/36/2.87\n\nRESP: RR 20-33 O2 sat 87-92% on 5L NC and Cool neb mask at 40%. ABG 7.45/27/53/19. NRB mask applied with O2 sat 95% and RR 20s. Pt cont with DOE with slight activity. LS coarse in upper lobes, crackles way up bilaterally.\n\nGI: +BS. Abdomen soft, non-tender. No BM since arrival to CCU. GI in to evaluate and do rectal exam, feels Cardiac/Resp issues are more concerning and should support Hct with transfusions for now. Protonix IV to be ordered. Taking sips of clear liquids.\n\nGU: Foley draining cyu- approx 200-300/hr. Additional 40mg IV Lasix given after arrival to CCU. AM Cr 2.6. Rcving Mucomyst dose on floor as prep for Cath. floor RN pt being tx for UTI with antbx.\n\nNeuro: A+Ox3. Very pleasant, quiet. MAE, following commands.\n\nSOC: , HCP and other relatives in to visit. MD and RN discussed code status, pt's wishes. Pt stated he would be intubated if necessary, but would not want to be shocked or have CPR. Family updated on status.\n\nA: NSTEMI, enzymes peaked and were trending down- today with rise in enzymes again. Acute SOB today- diuresing. GIB, with stable Hct trending down. Transfused with 1u PRBCs today. Reapro and Heparin d/c today in setting of new GIB.\n\nP: Assess Cardiac/Resp status. Meds per transfer orders. Follow labs: Hct, lytes, Coags.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-05 00:00:00.000", "description": "Report", "row_id": 1425067, "text": "CCU NPN 1900-0700\nO: afeb.\n\nHR 90-95afib- converted to NSR at 0200. rate 65-72. occas. PAC.\nBP 91-97/50's. tolerated lopressor 12.5mg dose at MN.\n\nnegative ~ 350cc for . u/o dropping off to 20cc/hr- given lasix 80mg IV at 0200- u/o inc. to 60-100cc/hr.\n\nRR 20-24. sats 93-96% on 100% NRB. LS crackles bases.\ndenies SOB. appearing comfortable. HOB 30deg.\n\nnatrecor contin. at .015mcq/k/min.\n\ntaking sips of water/GA.\n\nA: converted to NSR on po amio and lopressor\n fair responce to lasix.\n stable sats on NRB\nP: possible HD today pnd lab results. OOB to chair if able. follow u/o, sats. contin. natrecor gtt.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-05 00:00:00.000", "description": "Report", "row_id": 1425068, "text": "79 yr old admitted from osh on heparin and reopro,for cath ,developed gi bleed,tx 2 upc .HAD CK AND TRAPONIN BUMP. HX CRI,CREAT 4 ,STARTED ON NATRECOR.HAS HIGH O2 REQUIREMENTS .DIALYSIS DISCUSSED BUT NO DECISION MADE .STILL AWAITING CATH\n\nTODAY SR ,BP STABLE ON LOPRESSER .HCT STABLE,K REPLACED .\n\nWEANED FROM NONREBREATHER TO SIMPLE FM OR PRONGS TO KEEP SAT OVER 90.\n\nPOOR APPETITE ,BOOST OFFERED,STOOL P DULCOLAX .\n\nNOT MAINTAINING NEG BALANCE ,LAST LASIX DURING NIGHT\n\nALEET,ORIENTED ,COOP, CO PAIN LEFT LOWER FOREARM OLD IV SITE ,HOT PACK APPLIED .\n\nTOL LOWER O2 SETTING NEED DIALYSIS\nPOOR NUTRITION\n\nCHECK C HO ABOUT I/O\nFOLLOW HCTS,LYTES\nENCOURAGE PO INTAKE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-06 00:00:00.000", "description": "Report", "row_id": 1425069, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"IT IS REALLY DRY IN HERE\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3. TURNING SELF IN BED. MOVING ALL EXTREMITIES WELL. DENIES C/O DISCOMFORT. GIVEN 40 MEQ KCL PO LAST NOC.\n\nCV: HEART RHYTHM NSR RATE 85. AT 0600 HEART RATE DOWN TO 42 THEN INTO AFIB RATE 85. BP STABLE WHILE IN AFIB. EKG DONE. CCU RESIDENT AWARE.\n\nRESP: O2 6L NC, MAINTAINING O2 SAT 93%. LUNGS DIMINISHED. DENIES SOB.\n\nGI: BM X3, LARGE AMT LIQUID MELANA STOOL. DENIES N/V. APPETITE FAIR. TAKING SIPS OF WATER.\n\nGU: LASIX GIVEN LAST NIGHT, DIURESING FAIR. SEE FLOWSHEET FOR I/O.\n\nSKIN INTACT.\n\nSTABLE NOC, S/P GI BLEED, AFIB.\n\nP: FOLLOW I/O, HCT. ? TRANSFER TO FLOOR TODAY.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2185-12-28 00:00:00.000", "description": "Report", "row_id": 1703048, "text": "NPN DAYS\n\n1 Infant with Potential Sepsis\n\nInfant with Potential Sepsis: Antibiotics dc'd. LP on nights\nwas benign. Problem resolved.\n\nAlt in Resp: Received baby in 30% FiO2 200cc flow NC. Baby\nwas weaned to RA, then 100cc flow, NC taken off at 2pm and\nsats remain >95%. LS clear and equal with mild IC/SC\nretractions. RR 30's-60's. Chest tube site dsg CD&I. No\nspells this shift. Will continue to monitor for s/s resp\ndistress.\n\nAlt in FEN: TF 100cc/kg/day. Feeds of PE20 are currently at\n80cc/kg/day and IV of D10 with KCl and NaCl is infusing at\n20cc/kg/day. Baby will be advanced to full feeds with 6pm\ncares. Tolerating gavage feeds without problems. D/S 81. Np\nspits, no aspirates. No stool. Voidign qdiaper change. Will\nlet parents attempt bottle feed with 6pm cares.\n\nAlt in Dev: Temp stable under warmer. Baby swaddled when\nphototherapy dc'd. Awake and alert with cares. Stirs in\nbetween cares and settles nicely with pacifier. will\ncontinue to provide for developmental needs.\n\nAlt in Parenting: Mom and dad called for update. Will be in\nthis evening to visit. Updated parents on baby's progress\ntoday. Will continue to provide support and teaching.\n\nHyperbilirubinemia: Bili from last night 9.0/0.9. Bili\nlights shut off this am and rebound bili to be checked in\nthe am.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-29 00:00:00.000", "description": "Report", "row_id": 1703049, "text": "NPN\n\n\n#2 Resp- Remains in RA w/o2 sats 96-100%. BS clear. Mild\nretractions.RR- 40-70.Dressing CD+I.A= Stable in RA. P=\nMonitor.\n#3 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of Pe\n20cals w/lg spit x1. Minimal asps.NG time increased from\n30-40 mins. No other spits.Voiding in adeq amts. Lg mec\nstool x1.Wt down 50gms.D/S=85.TF= 100cc/kg/day.\n#5 Mom+ Dad here to visit x1. Updated on pt\ncondition. A= Involved. P= Support.\n#6 Bili-Sl jaundice.Bili drawn+ PND.\n#4 Dev-Moved to open crib.Adeq temps. See flowsheet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-29 00:00:00.000", "description": "Report", "row_id": 1703050, "text": "Neonatology Attending\n\nDOL 8 CGA 36 6/7 weeks\n\nStable in RA with sats >95%. R 50s-70s.\n\nOn 100 cc/kg/d PE20 mainly pg. DS 85. Voiding. Stooling. Wt 2495 grams (down 50).\n\nBili 6.2/0.5 rebound\n\nAntibiotics discontinued.\n\nStable temp in crib\n\nParents visiting. Mother sick with a cold today.\n\nA: Doing well. Stable in RA. Needs to learn to feed. Hyperbili resolved.\n\nP: Monitor\n Increase to 120 cc/kg/d\n Encourage pos\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-29 00:00:00.000", "description": "Report", "row_id": 1703051, "text": "Neonatology - Progress Note\n\n is active with good . AFOF. He is pink, well perfused, no murmur auscultated. He has mild subcostal retractions in room air. Breath sounds clear and equal. Abd soft, active bowel sounds, no loops. Voiding and stooling. Continue to require some pg feeds. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-31 00:00:00.000", "description": "Report", "row_id": 1703058, "text": "Neonatology Attending Progress Note:\n10 DOL\ndoing well\npo's slowly\non RA\noff antibiotics\nno spells\nBP=93/56\nwt up 30 g on 120 cc/kg/d\nPE: well appearing, AFOF, normal S1S2, no murmur, breath sounds. clear. abdomen benign, ext well perfused. aga.\nImp/Plan:x-35 week infant s/p RDS and pneumothorax now doing well, learning to po feed.\n--encourage po feeds\n--recheck blood pressure\n--d/c planning\n" }, { "category": "Nursing/other", "chartdate": "2185-12-31 00:00:00.000", "description": "Report", "row_id": 1703059, "text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in room air with O2 sats above 95. No apnea,\nbradycardia, or spontaneous desat noted. Breath sounds, ersp\nrate, and WOB are at baseline. Chest dsg removed and site\nbenign.\nA: o evidence of compromise.\nP: Monitor and assess.\n\nNUTRITION\nO: Remains on tF 120cc/kg/day of E20 with Iron. Attempting\nall po and infant is so far meeting volume requirement, but\nis slow to feed and feeding tube remains in place for\npotential supplement. One gastric aspirate was lightly blood\nstreaked, however stool is heme neg and no further\nrecurrence noted. Team aware.\nA: Borderline thriving.\nP: Assess intake on ad lib schedule and remove feeding tube\nwhen thriving.\nDEVELOPMENT\nO: Temp stable in open crib. Awake and alert for cares.\nSleeps between. Slow to feed po.\nA: Needs to learn feeding.\nP: Ad lib feeds. Support development.\n\nPARENTING\nO: Dad in for 1400 feeding. Handles infant fairly well.\nDiscussed potential for upcoming discharge home if infant\ncontinues to po over minimum requirement. Hepatits B vaccine\ngiven as consent was in place in chart. Parents plan to\nreturn for 1800 feeding.\nA: Invovled parent.\nP: Support and continue teaching for discharge.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-01 00:00:00.000", "description": "Report", "row_id": 1703060, "text": "NPN\n\n\n#2-O: In RA RR 40's-50's, clear and equal , sats 99-100\nconsistently.\n\n#3-O: TF 120cc/k/d E20 = 51cc q4 hrs, PO?PG , po'd fair for\n15-31cc. PG for remainder each time, min aspirates, no\nspits. Noted to have some stridor on inspiration while po\nfeeding. sl. uncoordinated when sucking/breathing. abd soft,\nactive bowel sounds, voiding and stooled soft yellow x 2.\nwt up 5 gms today to 2.550 kg\n\n#4-O; temp stable wrapped in crib, alert and active, no\nspells, no desats, afof, appropriate.\n\n#5-O; dad called x 1 , updated, will visit today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-28 00:00:00.000", "description": "Report", "row_id": 1703045, "text": "NPN 1900-0700\n\n\n1. SEPSIS: O: Day Ampi and Gent. LP done by \n. Results pending. A/P: Abx as ordered.\n\n2. RESP: O: Pt remains on nasal cannula, 200cc flow\nrequiring 25-30% FiO2. RR 30-60's. Mild S/C retractions\nnoted. Lung sounds are clear. No spells/desats noted. A:\nStable in cannula. P: Monitor.\n\n3. F&N: O: TF remain at 100cc/k/d. Feeds will be\nadvanced to 80cc/k/d of PE20 at 0600. Feeds gavaged in over\n30 minutes. Abd benign. BS+. A/G stable. IVF of D10 with\nlytes is infusing well via PIV. U/O 2.4cc/k/h. No stool\nnoted so far this shift. Weight gain 70 grams. A: Tol\nfeeds well. P: Monitor.\n\n4. DEV: O: Temp stable on radiant warmer. Active and\nalert during cares. Generalized edema improving. Sucking\nvigorously on pacifier. Tol LP well with sucrose pacifier.\nA: AGA. P: Continue to support infant's needs.\n\n5. PAR: O: Dad in to visit with his parents at . Mom\ncalled for update X1. A: Loving, vested family. P:\nContinue to support parents.\n\n6. HYPERBIL: O: Pt's jaundiced has imrpoved greatly since\nyesterday. He remains slightly jaundiced. He is under\nsingle phototherapy. Bili levels to be sent later this am.\nA: Hyperbilirubinemia. P: Bili lights and levels as\nordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-28 00:00:00.000", "description": "Report", "row_id": 1703046, "text": "Neonatology Attending\n\nDOL 7 CGA 36 6/7 weeks\n\nStable in NCO2 200cc 21-30%. O2 sats 95-100%. R 30s-60s. No A/B.\n\nBP 77/44 mean 60\n\nOn 100cc/kg/d with PE 20 at 80 cc/kg/d and IV D10+lytes 20 cc/kg/d. Advancing feeds 20 cc/kg q 12. DS 72/81. Voiding. No stool. Wt 2545 grams (up 70).\n\nOn phototherapy. Bili 9/0.9\n\nOn A/G D7/7. LP last night was benign 8 wbc 174 rbc prot 46 gluc 56. BC remains negative\n\nFamily visiting.\n\nA: Stable. Resolving O2 requirement. Tolerating feeds and advancing well. Hyperbili resolved. Antibiotic course complete.\n\nP: Monitor\n Wean O2\n Advance feeds\n D/C phototherapy and check rebound\n D/C A/G\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-28 00:00:00.000", "description": "Report", "row_id": 1703047, "text": " Physical Exam\n\nPE: pale pink, mild jaundice, AFOF, face slightly puffy, hoarse cry, breath sounds clear/equal with good air entry, mild subcostal retracting, chest tube dressing clean/dry without drainage, abd soft, non distended, + bowel sounds, no rashes, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2185-12-27 00:00:00.000", "description": "Report", "row_id": 1703040, "text": "Respiratory Care Note\nPt. began shift on nasal prong CPAP. Decision made to trial pt. off. Pt. has been on 300-500's of nasal cannula on 25-50%. RR in 40's. Looks comfortable. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-27 00:00:00.000", "description": "Report", "row_id": 1703041, "text": "Neonatology Attending\n\nDOL 6 CGA 36 5/7 weeks\n\nTransitioned to CPAP then NCO2 500 cc RA. O2 sats 95-100%. R 30s-60s. No A/B. CT discontinued yesterday after CXR with minimal residual pneumothorax.\n\nBP 69/42 mean 55\n\nOn 100 cc/kg/d. Feeds started at 40 cc/kg/d PE20 and advancing 20 cc/kg q 12. Taking some pos. Also on PN/IL at 60 cc/kg/d. Voiding 2.5 cc/kg/hr. Stooling. DS 88. Wt 2475 grams (up 15).\n\nBili 15.8/0.8. On phototherapy.\n\nOn A/G D .\n\nParents visiting and up to date.\n\nA: Resolving RDS. Now in RA but with flow. Tolerating feeds. Hyperbili being treated. Completing antibiotic course. Needs LP.\n\nP: Monitor\n Wean off NC flow\n Advance feeds\n Follow bili\n LP\n Complete antibiotic course\n" }, { "category": "Nursing/other", "chartdate": "2185-12-27 00:00:00.000", "description": "Report", "row_id": 1703042, "text": " Physical Exam\n\nPE: pink, well perfused, AF small, open, sutures approximated, breath sounds coarse, equal, mild subcostal retracting, dressing dry and intact right chest, no murmur +2/= pulses, abd soft, non distended, + bowel sounds, no rashes, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2185-12-27 00:00:00.000", "description": "Report", "row_id": 1703043, "text": "NICU nursing note\n\n\n1. Sepsis=O/Cont on Amp and Gent (day6:7). A/pot for\nsepsis. P/Cont with current Rx and plan LP.\n\n2. Resp=O/Presently on NCO2 200cc/min/flow FIO2 21-25%.\nLSC/E. (Refer to flowsheet for assessment.) Chest tube dsg\nCD&I. No spells. A/Stable on NCO2. P/cont to monitor for\nresp distress and wean from O2 as tol.\n\n3. FEN=O/TF cont at 100cc/k/d. 40cc/k/d=PE20 po/pg.\n60cc/k/d=PND10 via patent/intact PIV LUE. Abd. benign.\n(Please refer to flowsheet for assessment and po amts.)\nVoiding. No stool. Sm. spitx1. A/Tolerating current\nregime. P/Cont to monitor for feeding intolerance. Cont to\nadvance feeds . Will advance feeds 20cc/k/d at 1800.\n\n4. Dev=O/Temp stable on servo/. Alert and active with\ncare. Waking for feeds. Bottle fed by mom at 1400. A/Alt\nin G&D. P/Cont to monitor and support G&D.\n\n5. Parents=O/Mom in to visit this afternoon. Held baby for\nfirst time. Changed diaper, did cord care, and bottlefed.\nUpdated by and nursing. Spoke with about LP and\nconsent. Dad to be in later this evening. A/appropriate\nand actively involved. P/cont to support and educate\nparents.\n\n6. Hyperbili=O/cont on single phototx. Noticeably less\njaundiced. A/hyperbili. P/Cont with present Rx and obtain\nbili in am.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-28 00:00:00.000", "description": "Report", "row_id": 1703044, "text": "Neonatology NP Procedure Note\nLumbar Puncture\nIndication: r/o meningitis in the presence of presumed sepsis\nParental consent in chart\n20% sucrose given for analgesia\nInfant held in left lateral position. lumbar-sacral area prepped and draped. 0.2 cc 1% lidocaine given id at L4-5. 22 gauge 1 1/2inch spinal needle inserted at L4-5 2 cc clear CSf removed and sent to lab. Needle removed. Infant tolerated procedure well. No complications.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703038, "text": "Neonatology - Progress Note\n\n is active with good . AFOF. He is pink, well perfused, no murmur auscultated. s/p chest tube placement for ptx over weekend. Received on HFOV this AM. CXR this AM showed good expansion, possibly small amt residual air in mediastinal area. Infant taken off of HFOV and breathing comfortably on CpAP. Chest tube removed this afternoon after premedication with MSO4 .1mg. Infant comfortable without increased WOB after chest tube dc'd. He remains NPO. On parentaral nutrition. DS stable. Abd soft, active bowel sounds, no loops. Voidng and stooling. Lytes today wnl. Bili today 3.3/0.3. Phototherapy dc'd. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-29 00:00:00.000", "description": "Report", "row_id": 1703052, "text": "NPN DAYS\n\n6 HYPERBILIRUBINEMIA\n\nAlt in Resp: Remains in room air with O2 sats 97-100%. LS\nclear. Slightly diminished this afternoon in RLL. Mild IC/SC\nretractions. Dsg to right side of chest CD& and MD\naware of slightly diminished LS and examined baby. \ncontinue to closely observe baby for s/s resp distress.\n\nAlt in FEN: TF increased to 120cc/kg/day E20. Gavaging feeds\nover 50 mins. No spits. No aspirates. Belly benign. No\nstool. Will po feed baby with next set of cares if resp\nstatus is stable.\n\nAlt in Dev: Temp stable in open crib. awake and quietly\nalert with cares. Will continue to provide for developmental\nneeds.\n\nAlt in Parenting: Mom called x1 for update. Dad to be in\nthis afternoon to visit. Will continue with support and\nteaching.\n\nHyperbilirubinemia: Bili this am 6.2/0.5. Problem resolved.\n\nREVISIONS TO PATHWAY:\n\n 6 HYPERBILIRUBINEMIA; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-30 00:00:00.000", "description": "Report", "row_id": 1703053, "text": "1900-0730 NPN\n\n\nRESP: Pt cont in RA with RR 40's-60's, O2 sats 96-100%. LS\nclear/=, mild SC/IC retractions noted. No A/B spells or\ndesats. Right chest dsg is CD&I. A: Resp status stable.\nP: Cont to monitor.\n\nFEN: Birth weight=2550g. Tonight's weight=2515g, up 20g.\nTF are at 120cc/kg/d of E20 PO/PG. Pt bottlefed x 1 this\nshift for 5cc. No spits, no aspirates, abd girth stable at\n25cm. Abdomen soft, round, pink, BS+, no loops. Pt is\nvoiding, no stool this shift. A: Tolerating feeds at this\ntime, learning to PO feed. P: Cont to monitor feeding\ntolerance and encourage PO feeding.\n\nG&D: Temps stable in open crib, pt is dressed and swaddled.\nMAE, alert and active with cares. Sleeps between cares.\nSucks pacifier and brings hands to face for comfort.\nFontanels soft/flat. A: AGA. P: Cont to support growth and\ndevelopment.\n\nPARENTING: Dad in to visit x several hrs during evening,\nparticipated in care and held infant. Mom called x 1 for\nupdate. A: Parents loving and invested. P: Cont to\nsupport/educate parents.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-30 00:00:00.000", "description": "Report", "row_id": 1703054, "text": "Clinical Nutrition\nO:\n~37 wk CGA BB on DOL 9.\nWt: 2515 g (+20)(~25th to 50th %ile); birth wt: 2535 g. Wt currently down ~1% from birth wt.\nHC: n/a\nLN: n/a\nLabs not required.\nNutrition: TF @ 120 cc/kg/d E20, po/pg. Infant taking minimal amounts of po feeds, max. so far ~15 cc. PN was d/c'd on DOL 6. Projected intake from EN for next 24 hrs ~80 kcal/kg/d, ~1.7 g pro/kg/d.\nGI: Occasional med. to large spits. Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems except occasional spits as noted above. Labs not required. Initial goal for feedings is ~150 cc/kg/d E20, providing ~100 kcal/kg/d and ~2.2 g pro/kg/d. Further increases in feeds as per growth. Growth goals after initial diuresis are ~20 to 35 g/d for wt gain, ~1 cm/wk for LN gain, and ~0.5 to 1.0 cm/wk for HC gain. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-30 00:00:00.000", "description": "Report", "row_id": 1703055, "text": "Neonatology Attending\n\nDOL 9 CGA 36 4/7 weeks\n\nStable in RA. R 40s-60s. Sats > 95%.\n\nBP 85/52 mean 60.\n\nOn 120 cc/kg/d E 20 po/pg. Voiding. Stooling. Wt 2515 grams (up 20).\n\nFamily visiting.\n\nA: Stable. Needs to learn to feed.\n\nP: Monitor\n Encourage pos\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-27 00:00:00.000", "description": "Report", "row_id": 1703039, "text": "NPN 1900-0700\n\n\n1. : O: Day course of Ampi and Gent. A/P: Abx as\nordered.\n\n2. RESP: O: Pt was received on prong CPAP 6, requiring\n21%. Pt was put on nasal cannula 500cc flow, FiO2 25-30% at\n2100. RR 30-60's. Mild IC/SC retractions. Lung sounds are\nclear and good aeration is heard. No required. A:\nStable on cannula. P: Monitor.\n\n3. F&N: O: TF increased to 100cc/k/d this shift. IV was\nout at start of shift and RN, and Attending were unable\nto successfully start another IV. Decision was made to feed\npt if he did well on nasal cannula. He bottled 17cc well at\n2200 with Dad. D/S 75. IV was replaced and pt bottled 17cc\nat 0200 (40cc/k/d). U/O was only 2cc at that time. Plan is\nto continue feeds at 40cc/k/d of PE20 and infuse IV PND10 at\n60cc/k/d. Feeds will be advanced by 20cc/k/d at 0200/1400.\nAbd soft and flat. BS+. A/G stable. No loops, spits or\naspirates noted. U/O 2.5cc/k/h. No stool noted so far this\nshift. A: Started feeds. P: Monitor.\n\n4. DEV: O: is active and alert during his cares.\nTemp stable nested on sheepskin on servo-radiant warmer.\nMAE. Fontanels are soft and flat. Sucking vigorously on\npacifier at times. Chest tube dsg is C&D&I. A: AGA. P:\nContinue to support infant's needs.\n\n5. PAR: O: Dad in to visit this evening. He held \nfor the first time and he stated that he was very pleased.\nHe spoke lovingly to and asked appropriate questions.\nHe called X1. A: Loving, vested family in crisis. P:\nContinue to support parents.\n\n6. HYPERBIL: O: Pt is jaundiced. Bili sent at change of\nshift was 15.8/0.8/15.0. Single phototherapy applied. A:\nHyperbilirubinemia. P: Bili lights and levels as ordered.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703032, "text": "NPN\n\n\n#1 Sepsis-Remains in Amp+ Gent.\n#2 Resp-Remains On vent in 26-30% o2,Map=8,Delta P\ndecreased to 24 from 26 after\nCBG=49/47/7.40/30/2.RR=20-40.BS clear. x1 for sm amts.\n#3 F/N- Abd soft,+bs, no loops. Remains NPO.D/S=71.PIV\npatent infusing TPN+ IL at 60cc/kg/day.Uo=2.6cc/kg/hr.No\nstool tonight.\n#5 Mom called x1. Updated on pt condition.A=\ninvolved. p= Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703033, "text": "Nurs adden\n\n\n#2 Resp-R chest tube placed to H20 seal.No drainage.\ndressing D+I.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703034, "text": "Neonatology Attending\nExam On prong CPAP, comfortable, + hiccoughs, clear bs, good aeration, no murmur, soft abd, normal bs, no hsm, awake and alert, good perfusion, normal \n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703035, "text": "Neonatology Attending\n\nDOL 5 CGA 35 5/7 weeks\n\nRemains on 26-30%/MAP 8/amp 24. R 30s. Chest tube to waterseal since 2am. 7.40/47 on amp 26.\n\nBP 77/49 mean 57\n\nNPO on 60 cc/kg/d PN10/IL peripherally. DS 71 141/3.5/108/22 Voiding. No stool. Birthwt 2575 grams\n\nBili 13.3/0.7\n\nOn A/G D5/7\n\nIntermittent MSO4 for pain control\n\nParents visiting and up to date\n\nA: Improving. RDS resolving. Presumed sepsis being treated. On low settings. CT now on waterseal. be ready for transition to CPAP today.\n\nP: CXR to check for residual pneumothorax\n CPAP if no reaccumulation\n D/C CT if stable\n Increase to 80 cc/kg/d\n Consider feeds if resp status stable on CPAP\n Follow bili\n Continue antibiotics for 7 day course.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703036, "text": "Respiratory Care\nRecv'd baby on hi-fi, baby extubated to cpap of 6, fio2 25%, Bs clear, slightly diminished to r lower lobe area, sx small white secretions, rr30's. Will continue to follow and support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703037, "text": "NICU nursing note\n\n\n1. Sepsis=O/cont on Amp and Gent. P/cont with current Rx\nand cont to monitor for s/sx infection.\n\n2. Resp=O/Received on . Placed on prong CPAP of 6\nafter CXRAY obtained this am. FIO2 25%. LSC/E. (Please\nrefer to flowsheet for assessment and sxning.) Chest tube\nremoved by this shift. A/Stable on CPAP. P/Cont to\nmonitor for resp distress.\n\n3. FEN=O/TF increased to 80cc/k/d. PND10 with intralipids\ninfusing via patent/intact PIV RLE. Heplock intact/patent\nRUE. Abd. benign. (Refer to flowsheet for assessment.)\nVoiding. No stool. A/Alt in FEN. P/Cont with current\nregime.\n\n4. Dev=O/Temp stable on servo/. Sleeping well between\ncares. Awake and alert for very short periods. Medicated\nwith MSO4 prior to chest tube removal. A/Alt in G&D. Pain\nwell controlled. P/Cont to monitor and support G&D.\n\n5. Parents=O/Mom in to visit this afternoon. Updated by\nnursing and . Dad to be in later this shift.\nA/Appropriate and actively involved. P/Cont to support and\neducate parents.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-25 00:00:00.000", "description": "Report", "row_id": 1703027, "text": "Neonatology Attending\n\nDay 4\n\nRemains on HFOV with MAP 8 Delta P 26 Fio2 0.35-0.4. ABG 7.26/66/87. Delta P increased in response. Chest tube bubbling. Draining 1-2 cc per shift. No murmur. HR 110-130. BP means 40-50s. NPO. TF at 60 cc/kg/d. Blood glucose 83. On PN and lipids. Urine output 2 cc/kg/hr. Day ampicillin and gentamicin. Gent levels 0.5/7.3. On MSO4 every 4 hours. Stable temperature on open crib.\n\nMild hypercarbia on HFOV. Pain control may be contributing. Will repeat ABG this morning. Will continue with thoracostomy tube to suction. Will repeat lytes tomorrow. Will consider feeding tomorrow. Trying to increase narcotic administration interval. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703022, "text": "NPN 7A-7P\n\n\n#1 Remains on amp and gent (on planned days for\ntreatment). Blood culture neg to date, admission CBC w/diff\nunremarkable. Will con't to monitor for S&S of sepsis. To\nobtain gent level at this evening's dose.\n\n#2 Remains on unchanged hi-fi vent settings, Fi02 35-37%\nthis hift w/Sao2's in mid 90's. No desat's or brady's. RR\n50's and observable. LS clear. Rt side CT intact and\ndraining very small amount blood-tinged fluid, chamber\nbubbling actively. Dressing site dry and intact w/o\ndrainage/leakage. Infant appears comfortable, given MSO4 q\n3-4hrs prn for repositioning and IV restart. Plan to obtain\nCXR this afternoon. Plan as per status/CXR results.\n\n#3 Remains NPO, TF at 60cc/k/d of D10TPN w/IL via PIV.\nAnother IV started in foot for slight hand site puffiness,\nflushed well but resting site at present. Is voiding well,\nno stool but has + bowel sounds. Monitor.\n\n#4 36+ weeker, NPO on Hi-Fi w/pneumothorax. Respiratory\nstatus stable, CV status stable, appears comfortable and\ngiven pain control as needed. Turning infant q12 hrs w/cares\nq 6hrs (clustered w/activites when appropriate). Con't to\nassess/monitor.\n\n#5 Parents in to visit this AM, updated at bedside.\nAppropriately concerned about infant's status but reassured\nby infant's presenting stability. Mom states infant's\n4-yr-old sister at home has been sick with a stomach flu so\nparents stayed briefly and have called x 2 today. Will visit\ninfant again tomorrow as long as parents con't to feel well\nthemselves. Con't to update/support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703023, "text": "Respiratory Care\nPt cont on HFOV. Fio2 .38, bs clear, rr 50s', sx for mod amt. Increased AMP to 20 following cbg 7.25/65. CT to sx. bubbling actively. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703024, "text": "NPN Addendum:\nCXR done, infant evaluated by team, no apparent changes in respiratory or general status at this time. Sao2's continue in high 90's in 35-37% fi02.Cap gas: 7.25-55-p02 65 30/0. Hi-Fi amp increased to 20. Infant appears uncompromised at this time, RR30-50's with unlabored breathing. CT chamber bubbling, site intact. Will con't to monitor status, WOB, and any required fi02 increases to mainatin sao2's.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-25 00:00:00.000", "description": "Report", "row_id": 1703025, "text": "NPN\n\n\n#1 Sepsis- Remains on Amp+ Gent.\n#2 Resp- Remains on vent in 34-45% o2,MAP-8,Delta P\nincreased from 20 to 26 after CBG=41/72/7.24/32/0.Follow up\nABG=87/66/7.26/31/0.BS clear. Sxn x2. Mild retractions.RR=\n30-50.R CT bubbling to sxn. Draining 1cc. Dressing\nD+I.Morphine x2 for pain.A= Increased settings. p= monitor.\n#3 F/N- D/S=83.PIV patent infusing at 60cc/kg/day of TPN+\nIL.Voiding in adeq amts. No stool.Abd soft,+bs, no loops.\n#5 Dad called x1. Updated on pt condition.A=\nInvolved. p= Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-25 00:00:00.000", "description": "Report", "row_id": 1703026, "text": "Respiratory Care\nBaby rec'd on HFOV with MAP 8, amp 20, 38%. Baby repositioned @ 2200. for mod amt pale yellow sec. BS clear. R CT in place. CBG: 7.24/72/41/32/0; amp increased to 26. for sm white sec. ABG: 7.26/66/87/31/0; no changes made @ this time. 02 req this shift 34-50%. MS04 x2. Will cont to follow closely, support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-25 00:00:00.000", "description": "Report", "row_id": 1703028, "text": " Physical Exam\n\nPE: pink, well perfused, AFOF, less edema, orally intubated, breath sounds with hand bagging clear/equal with fair to good air entry, right chest tube in place, spontaneous breathing with mild retracting, no murmur, +2/= pulses, abd soft, non distended, + bowel sounds, active with exam, good .\n" }, { "category": "Nursing/other", "chartdate": "2185-12-25 00:00:00.000", "description": "Report", "row_id": 1703029, "text": "NPN 7A-7P\n\n\n#1 Remains on amp and gent, plan to treat x 7days (on day\n4). Blood culture remains negative. Monitor for S&S of\nsepsis.\n\n#2 On unchanged Hi-Fi settings after gas, fi02 28-37%,\nSa02 consistently >94%. LS auscultated during repositioning\nwith PPV, are fairly = and clear. Very shallow breathing at\nbeginning of shift but now has observable RR at 30-50's. Rt\nCT draining 1-2 cc's per shift of slightly bloody fluid,\nsite/dressing intact. Will con't to moniotr closely for\nincreased Fi02 requirement and WOB. Plan as per infant\nstatus.\n\n#3 Remains NPO, TF also remain at 60cc/k/d of TPN + IL.\nD/S:85. Has + bowel sounds. Not given MS04 as frequently\ntoday due to less handling/comfortable status. Assess for\nreadiness of enteric feeds soon.\n\n#4 Rec'd 1 dose MS04 at 12 n today (approx 12 hrs after last\ndoese) due to increased agitation. Irritabililty has\ndecreased and has longer periods of resting comfortably\nnow.Eyes open at times, has mild dependant edema at eyes and\nextremities but is repositioned q 12 hrs, w/cares q 6hrs and\nprn. Will con't present comfort measures and to assesss for\npain.\n\n#5 Mom called x 1 this AM and was in to visit this\nafternoon. Dad plans on visiting also this evening. Mom\nupdated at bedside, asking alot of questions and needing\nsome reassurance of infat's comfort. Appropriately concerned\nparents, con't to update and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-25 00:00:00.000", "description": "Report", "row_id": 1703030, "text": "Respiratory Care\nPt cont on HFOV. Fio2 .30, bs clear, rr 30-40, sx for mod amt. cbg drawn today.: 7.39/50. No changes made. Right CT to sx, some drainage noted. Plan to support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-26 00:00:00.000", "description": "Report", "row_id": 1703031, "text": "Respiratory Care\nBaby rec'd on HFOV with MAP 8, amp 26, 15 Hz. Repositioned @ 2200- tol well. BS clear. for sm amt white sec. R CT in place. CBG: 7.40/47/49/30/2; amp decresed to 24. 02 req this shift 26-30%. Will cont to follow closely, support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-30 00:00:00.000", "description": "Report", "row_id": 1703056, "text": "2. remains in RA, color pink-sl jaundice, RR 40-60, sc\nrets, BBS clear and equal, no spells, rt ct site with dry\nand intact dressing A: stable respiratory P: continue to\nmonitor.\n3. TF 120cc/k/d E20 with Fe 51cc q4h, took 35 and 33cc po,\nremainder given pg, abd soft, voiding and passing neg stool\nA: learning to po P: continue to encourage po feedings.\n4. waking for most feedings, active and alert with cares,\ntemps stable swaddled in open crib P: continue to support\ngrowth and development.\n5. Mom here for 2pm feeding, very involved and concerned,\ncontinue to update and offer support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-31 00:00:00.000", "description": "Report", "row_id": 1703057, "text": "#2 RA, SATS >95%. LS ARE CLEAR. INCREASED WOB WITH PO FEEDS.\nNO BRADY'S OR DESATS. CHEST TUBE DSG DRY AND INTACT.\n#3 TF 120CC/KG E20. PT SLOW TO PO, UNCOORDINATED, INCREASED\nWOB WITH PO. MOD SPIT X1, ABD BENIGN. VOIDING AND STOOLING.\nWEIGHT INCREASE 30GM.\n#4 TEMPS ARE STABLE IN OPEN CRIB. QUIETLY ALERT WITH FEEDS.\nPOOR PO FEEDING. PASSED HEARING SCREEN.\n#5 MOM X1 FOR UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703012, "text": "Respiratory care\nbaby intubated from cpap for ^ wob,and ^ fio2 req.3.5 ett placed ,and started on r20 20/5.Given 10cc survanta @ 9;30pm,tol well.AbG drawn 7.39/38/47/21/-1 decreased r18 and ^ peep to 6.Baby had continued tacypnea,gave 3rd dose survanta @ 5;30 am.Weaned pip to 18 for ^ Vt.Baby then noted to have ^ fio2 req and retractions,^ pip back to 20,but still having desats,BS found decreased aeration on R side,transilluminated and R side +.CXR done and showed R pnuemo.Tried to needle asp but continuous leak noted.Switched baby to ,and placed R C.T.Initial settings MAP 8 AMP 20 100%.ABG 7.39/40/164/25/0 decreased amp 18 and weaned fio2,remains on map 8.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703013, "text": "NPN\n\n\n#1 Sepsis-Remains on Amp+ Gent.\n#2 Resp-Intubated from CPAP for increased WOB+ o2 need.Surf\ndoses 2+3 given.Settings weaned. See flowsheet for settings\n+ABG's.BS clear.Mild to mod retractions.Dim on R.R chest\nneedled after x-ray and chest tube placed and put to\nsxn.Draining sm amts of blood.Placed on vent now in 38%\no2,Map =8.Amp=18.see flowsheet.\n#3 F/N-Lg spits x2. Made NPO.PIV patent infusing at\n60cc/kg/day.Abd soft.+bs, no loops.Voiding+ stooling in adeq\namts.\n#5 Parents here to visit in PM. Mom here to visit in\nAM.Talked at length w/+MD.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703006, "text": "Neonatology\nRemains on vent this am. Currently on 20/5 rate 14 and low fIo2 (24%-35%). No evidence of PDA. Heart size generous on CXR. ALveolar infiltrate. CV stable. No evidence of PDA. WIll hold on second dose dose of surfactanct. Plan to slowly \n\n\nWt 2535. NPO at present. D10W at 60 cc/k/d. BS in good range. Abdomen slight distended but soft.\n\nClinically stable on abx.\n\nNot jaundiced will follow.\n\nFamily meeting to be planned.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703007, "text": "Social Work\nFamily mtng this afternoon w/ this , NP, RN, and parents to discuss baby's medical status and course prior to discharge. Parents live in and have a 4 yo dtr, who has already seen the baby. Couple will figure out the logistics of their visits w/ the baby once mother is d'c'd. Father is currently intwtween employements and has the time off for the next couple of weeks as needed. he will care for the 4 yo to enable his wife to visit the NICU. Parents involved and supportive, asking appropriate questions during the mtng. They were given parent packet and my card.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703008, "text": "Respiratory Care\nPt recieved on SIMV, rate of 20, pressures of 20/5 with the fio2 23 to 30%. PT suctioned for a sm amt of thick white secretions. Pt weaned down to rate of 14 with good blood gas results. Pt extubated to nasal cannula briefly, then placed on NP-CPAP +6cm's with the fio2 30 to 40%. PT's respiratory rates 60's to 90's. Plan is to watch WOB. Consider repeat CXR or 2nd dose of surf if WOB increases.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703009, "text": "NPN 0700-1900\n\n\nSepsis: Infant cont on abx, amp and gent as ordered. BC\nNGTD.\n\nRESP: Received infant intubated on 20/5 X20. Rate was\nweaned, per RT and good gases. Infant was extubated at 1100\nto NC, 300cc 100% FiO2. Increased WOB noted. Infant placed\non NP CPAP 6, FiO2 30%. Last CBG at 1300 was 7.35/38. Infant\ncurrently on NP CPAP 6, FiO2 40%. RR60-80's, occ 90-100's.\nO2sat >93%, with drifts to low 90%'s, requiring incr in\nFiO2. Mild/mod IC/SC rtx noted, occasional grunting heard.\nLS clear and equal with good aeration.\n\nFEN: TF=60cc/kg/d. Currently receiving IVF of D10W at\n30cc/kg via scalp PIV. Infant started enteral feeds of PE20\nat 30cc/kg. Equals 13cc q4hrs via NGT. Belly soft and round.\n+BS, AG stable. No loops, spitX2, min asp. Voiding,\nUO=1.2cc/kg/hr X12hrs. Sm mec stool X1. D-stick 98 & 70.\n\nDEV: AFSF. MAE. Temp stable, nested on open warmer. Alert\nand active with cares. Slightly irritable at times.\n\nParents: Mom and dad at bedside throughout the day. Updated\nby this RN and RT . Had family meeting at 1520\nwith Rivers, SW and this RN. Asking appropriate\nquestions, appear loving and concerned. Mom took temp and\nchanged diaper. Mom held infant for approx 20min. Mom to be\ndischarged tomorrow. Plan on visiting later tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703010, "text": "Procedure Note: Intubation\nIndication: respiratory distress, surfactant administration\n\n#3.5 ETT passed orally and advanced through cords under direct visualization. Taped at 10 cm mark with equal breath sounds. Chest x-ray shows tip position mid-trachea. Infant tolerated procedure well. No complications.\n" }, { "category": "Nursing/other", "chartdate": "2186-01-05 00:00:00.000", "description": "Report", "row_id": 1703075, "text": "1900-0700 NPN\n\n\n#2RESPIRATORY\nO:REMAINS IN RA WITH SATS 98-100%. RESP RATE 36-50 WIHTOUT\nDISTRESS. BS CLEAR. DESAT X2 AT START OF FIRST TWO FEEDS-ONE\nOF WHICH REQUIRED BB02 FOR RECOVERY.\nA:DESAT REQUIRING BB02\nP:CONTINUE TO MONITOR RESP STATUS/SPELLS\n\n#3F/E/N\nO:TF AT 100CC/KG E24. BABY TAKING 55-60CC Q4HR HT\nALL PO. SMALL AND MOD SPIT AFTER EACH OF FIRST TWO FEEDS\nTHIS SHIFT. ABDOMEN SOFT, FULL WITH GOOD B.S. WT DOWN 5 GM\n(STILL BELOW BW). DESATS AT START OF EACH OF THE FIRST TWO\nFEEDS\nA:IMPROVED VOLUME BUT NOW DESAT/UNCOORDINATED\nP:CONTINUE TO ENCOURAGE PO'S, MONITOR SPITS AND SPELLS\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE IWTH CARES;\nSLEEPING WELL BETWEEN. WOKE BEFORE TWO OF HIS FEEDS PRIOR TO\nFEEDING TIME. FONTANEL SOFT AND FLAT; SUTURES SMOOTH.\nA:AGA\nP:CONTINUE TO MONITOR AND SUPPORT\n\n#5PARENTING\nO:DAD X1 OVERNIGHT. AWARE OF DESAT REQUIRING BB02\nWITH FEEDING. AWARE THAT BABY CAN NOT GO HOME IF HE IS\nHAVING DESATS. DAD AWARE NOT ABLE TO BE DONE.\nA:INVOLVED, INVESTED PARENTS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\nDR. (COVERING FOR OVERNIGHT) PAGED AND\nCALLED BACK RE:. DR STATED HE WAS UNABLE TO DO\n TONIGHT AND THAT SOMEONE WOULD HAVE TO DO IT THURSDAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-06 00:00:00.000", "description": "Report", "row_id": 1703076, "text": "Neonatology Attending\n\nDOL 16 CGA 37 4/7 weeks\n\nStable in RA. No desats or feeding coordination issues.\n\nBP 71/45 mean 50\n\nOn ad lib feeds. Took 126 cc/kg E24 yest. Voiding. Stooling. Wt 2465 grams (up 90).\n\n done and healing. Received tylenol for pain control.\n\nCar seat test passed. Hearing screen passed. Hep B vaccine given. PKU sent.\n\nFamily visiting and up to date.\n\nA: Doing well. No further issues with coordination. Ready for discharge.\n\nP: Home today\n f/u Dr. on Monday\n VNA\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-06 00:00:00.000", "description": "Report", "row_id": 1703077, "text": "Nursing Progress Note and Discharge Note\n\n\n2. RESP O/A Rec'd inf in RA. Inf remains in RA with sats\n96-100%. No desats w/ feeds. P discharge to home w/\nparents.\n3. FEN O/A TF=min 100cc/kg/day of E24. Inf PO feeding\n40-65cc each feed. Tol well. No spits. Belly soft, no\nloops. Voiding, stooling guiac neg. care done. Area\nred, no discharge. P discharge inf home w/parents.\n4. DEV O/A remains in an open crib with stable temp.\n A/A w/cares. Waking for some feeds. P discharge inf home\nwith parents.\n5. Parents O/A Mom and DAd in for cares and D/C. P\nSupport, d/c inf to home.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-21 00:00:00.000", "description": "Report", "row_id": 1703003, "text": "Neonatology NP Procedure Note\nEndotracheal Intubation\nIndication: need for surfactant administration\n3.0 ett passed orally through cords under direct laryngoscopy. tube secured with 9 at upper lip. good chest wall movement and equal breath sounds present. Infant tolerate procedure well. No complications.\nCXR pending to confirm tube placement.\nOf note infant has a slightly high arched palate and a frenulum from upper lip to mid upper gum line.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703004, "text": "RESPIRATORY CARE NOTE\nBaby 35 born at 1503 hrs . Wt 2535 grams apgars 8 & 8. Baby was brought to the NICU for observation. CxR taken at 7pm. Baby cont to have increase work of breathing. hrs Placed on NP CPAP 6 FiO2 30-34%. At 2315 hrs decision made to intubate baby and given survanta. Baby was intubated with a 3.0 ETT taped a 9cm. Survanta 10cc given at 2330hrs. CxR ETT high, pushed into 10cm. Baby was placed on vent settings 24/5 rate 20 FiO2 30%. Good chest expansion after survanta settings weaned to 22/5 rate 20. Cap gas PO2 32 CO2 46 PH 7.34. Pressures decreased to 20/5 Rate 20 Fio2 23%. Second dose of survanta held at this time. Stable on current vent settings cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 1703005, "text": "NPN\n\n\nNPN#1 O= remains on IV Abx ampi & gent as ordered, WBC 17.2\ndiff..60N/ 2B/ 31L...active with cares/ good , blood cx\npnd A= r/o sepsis P= cont per plan, assess for any S&S of\nsepsis\n\nNPN#2 O= received infant on NCO2 100% in 400cc flow..chest\nxray obtained..placed of NPCPAP of 6cm in mostly\n30-34%FIO2..continued with ^ WOB/O2 requirement...orally\nintubated with # 2.5ETT and x1 dose of survanta\ngiven...settings weaned since to present pressures of\n20/5x20 in O2 of 23-25% last couple og hours..decrease WOB\nsince intubation with only mild IC/SCR... LS clear & equal\nRR high 70's-80's..x1 CBG obtained at 0145..32/ 46/ 7.34/26/\n-2..settings weaned ..second dose of survanta on hold for\nnow A=initially ? TTN now RDS with surfacant def...improved\nafter intubation/ survanta P= cont to monitor resp status\nclosely..assess for ^ WOB/ ^ FIO2 requirement..cont. to\nassess need for second dose of survanta\n\nNPN#3 O= BW 2535gms, NPO with TF at 60cc/kg/d of D10W\ninfusing well via scalp IV..DS 95-101, abd exam soft + BS,\nabd did get distended after CPAP..FT place to decompress and\nleft OTA to vent...x2 sm mec stools, voied x1 for 1cc/kghr\novernight,A=stable DS P=I & O,follow DS, cont per plan\n\nNPN#4 O= remains on warmer weaning servo with stable temp,\nactive & alert with cares with good , , nested in\nsheepskin with boundaries in place, AF soft & flat A= AGA P=\ncont to assess & support dev needs\n\nNPN#5 O=parents up several times over night updated at\nbedside by team..asking lots of questions..appropriately\nconcerned A= involved & loving new parents P= cont to keep\nupdated & support, cont teaching as needed\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-04 00:00:00.000", "description": "Report", "row_id": 1703071, "text": "NPN 7p7a\n\n\n is on RA with sats >95%. LSC&E. Stridor still\naudalble especially when bottling but improved from last\nevening. No desats. S/C rtxs. Infant tolerating RA. Cont to\nmonitor .\n weighs 2380 (+15). He is on a 100 cc/k/d min E20. He\ntook 120cc/k/d in the last 24hrs. He has bottled well during\nthis shift, frequent stopping and burping but his\nco-ordination has improved. He has taken adequate amts thus\nfar this shift and has not needed to be gavaged. Abd benign,\nstooling and voiding. Infant tolerating TF. Learning to PO.\nCont to monitor weight and exam and encourage PO.\n is in an open crib with stable temps. He awakens\nduring cares but is passive at times. He does not wake on\nhis own to feed. He passed his car seat test. Parents were\nalerted that car seat is really too big for as the belt\ndoes not fit snuggly through his legs. They were advised to\nobtain a smaller carseat for safety. AGA. Cont to support\ndevelopment.\n Father called this am for update on weight and feedings.\nUpdated re car seat. Will be in tomorrow. Anticipate DC home\nsoon. It was agreed that would only be appropiate if is\ngaining weight and taking enough formula. Involved invested\nparents. Cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-04 00:00:00.000", "description": "Report", "row_id": 1703072, "text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. In room air, BS clear and equal with mild intercostal/subcostal retractions, color pink. RRR, soft murmur on auscultation, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Noncirced male, testes down bilaterally. Without rashes. Good , AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2186-01-04 00:00:00.000", "description": "Report", "row_id": 1703073, "text": "Neonatology Attending\nDay 14\n(CGA 37 2)\n\nRA. no A&Bs. RR40-50s. +Int stridor seen w/ bottling. HR 120-160s. BP 78/55, 65.\n\nWt 2380, up 15 gms. E20 po ad lib min 100cc/k/day (TF: 109). Abd benign. Tol feedings well. Nl voiding and stooling.\n\nIn open crib.\n\nPlan:\n - Improving po intakes. Consider increase cals.\n - Family would like circ prior to discharge.\n - Will need to assess need for synagis.\n - Will discuss discharge planning with family when they come in.\n" }, { "category": "Nursing/other", "chartdate": "2186-01-04 00:00:00.000", "description": "Report", "row_id": 1703074, "text": "Nursing Progress note\n\n\n#2 O: remains in room air w/sats 96-100%. Lungs\nclear/equal,color pink. RR 40-60's, baseline SCR. Murmur\npresent, soft. HR 120's-160's. stridor heard w/bottles, not\nat rest. A: stable O2 sats P: cont to monitor, monitor\nstridor.\n# O: Min 100cc/k/d 45cc q4h, adv to E24cals at 1400 to\noptimize weight gain. Feeding tube dc'd. starts out bottling\nwell but gets stridorous which slows feeding down and inc\namt of air baby is swallowing. Gets very tired, needs MUCH\nencouragement and frequent burping to take minimum amt.\nWakes on own for feeds, and active. A: slow po's r/t\nstridor, some immaturity P: cont to feed as above to see if\nbaby able to gain weight and take minimum amt. ? circ\ntomorrow.\n#5 O: parents called this morning, in to visit w/sib this\nafternoon. told re: car seat needing to fit better/straps\ntoo taut/too much room between them nd baby, and feeds as\nabove. Parents still want baby home tomorrow. Spoke w/Dr.\n re above, will see how well baby eats over next\n24hours.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-21 00:00:00.000", "description": "Report", "row_id": 1703001, "text": "Admission Note\n35 wk GA male admitted with respiratory distress\n\nMaternal Hx - 30 year old G2P1->2 woman with the following antenatal screens: O positive, antibody negative, HBsAg negative, RPR non-reactive, rubella immune, GBS negative.\n\nPregnancy Hx - for EGA 35-6/7 weeks. Pregnancy reportedly complicated by oligohydramnios noted at 35 weeks, leading to induction. Progressed to SVD under epidural anesthesia, with reportedly precipitous second stage. AROM 7 hours prior to delivery, yielding clear amniotic fluid. No maternal fever or fetal tachycardia. No intrapartum antibiotics administered.\n\nNeonatal course - Infant well at delivery. Apgar scores 8 at one minute, 8 at five minutes.\n\nPE\nhr 164 rr 74 SaO2 95% in 0.21 FIO2.\nBW 2535 (50-75th %ile) OFC 32.5cm (50th %ile) LN 47.5 cm (75th %ile)\nHEENT AFSF; non-dysmorphic; palate intact; mild nasal flaring; neck/mouth normal\nCHEST mild retractions and grunting respirations; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal male genitalia; testes descended bilaterally\nCNS active, alert, responsive to stim; tone AGA; moving all limbs symmetrically; suck/root/gag/grasp/Moro normal\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nImpression\n35-week GA male with\n1. Moderate respiratory distress. Currently in room air with mild to moderate symptoms. Most likely etiologies include perinatal transition, retained fetal lung fluid, or (less likely) pneumonia.\n2. Sepsis risk, based on moderately preterm labor as well as respiratory symptoms.\n\nPlan\nInfant has been admitted for cardiorespiratory monitoring. If distress persists, we will undertake further investigations including chest radiograph and blood gas. Will maintain SaO2 94-98% and consider CPAP or further interventions if respiratory distress worsens or oxygen requirement increases.\n\nWe will continue to monitor cardiac examination and maintain mean BP > 40 mmHg.\n\nFeeds will be withheld until cardiorespiratory stability is established. In the interim, IV maintenance fluids will be provided. Electrolytes will be followed if this persists beyond 12-24 hours. Capillary glucose will be followed.\n\nA CBC and blood culture have been drawn and broad spectrum antibiotic therapy started for anticipated course of 48 hours pending results of culture and WBC, as well as resolution of clinical symptoms.\n\nParents will be updated.\n\nOB: Dr. \n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-21 00:00:00.000", "description": "Report", "row_id": 1703002, "text": "Nursing NICU Admit Note\nPlease refer to above Attending Note.\nPt received from L&D. Skin pale-pink. Placed on radiant warmer. Please refer to flowsheet for VSS obtained. Babycares given. Pt received NS bolus X1 for BP mean 33. Pt noted for grunting and retractions. LS= good aeration bilat. Sepsis evaluation done. Pt started on Amp and Gent. Several attempts made to obtain PIV. D10W intiated via PIV at 60cc/k/d. Pt NPO. Parents in to visit pt. Updated on pt's status by this nurse .\nGrunting and retracting persisted. in to see pt. CXR obtained.\nID bands verified with L&D nurse.\n" }, { "category": "Nursing/other", "chartdate": "2186-01-03 00:00:00.000", "description": "Report", "row_id": 1703067, "text": "NPN 7p-7a\n\n\n conts on RA. RR 40-60. S/C rtxs. LSC& \nassess lung sounds as this writter thought right side might\nbe diminished. felt LS clear thru out. Sats > 93%.\nStridor evident during bottling without desats. Tongue seems\nto fall towards the back of mouth when sleeping and causes\ninfant to snore. Infant tolerating RA. Monitor and support\nresp status.\n has a new murmur audable to the right of the sternum.\n aware. Positive pulses. Infant is pale. BP stable. Cont\nto monitor and support CV status.\n is 2365 g (+10). He is poing all feeds this evening\nthus far. He dcd his NG tube before his 1st evening feed. At\nthat time he took 50cc, he later took 43 cc. Will assess at\nnext feed if he needs NG replaced to maintain TF 120cc/k/d\nE20. Pos over 30-40 mins per parents and MD request. Does\nwell initally but when tired lets tongue fall to back and\nstruggles with co-ordination. Abd soft, benign. No spits.\nVoiding but no stooling thus far this shift. Infant\ntolerating TF, mostly po. need pg if falling short of\nfluid goals. Encourage po. Monitor weight and exam.\n is in an open crib, with stable temps, swaddled. He\nawakens for some feeds and is alert with cares. He finds his\nhands and sucks on pacifier with support. MAEs. Font S&F.\nSome co-ordination difficulty with feedings. AGA. Cont to\nmonitor and support development.\n father called this PM. Asking appropiate questions.\nFM held today and another scheduled for wednesday. Parents\nanxious to get home. Plan is to encourage PO feedings.\nParents want VNA to come into home and do daily weights. \nwill speak with pedi tomorrow concerning home\nwith VNA support. Loving invested parents. Cont to support\nand educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-03 00:00:00.000", "description": "Report", "row_id": 1703068, "text": "Neonatology Attending\n\nDOL 13 CGA 37 5/7 weeks\n\nStable in RA. No desats.\n\nMurmur noted last night.\n\nOn 120 cc/kg/d E 20. Takes 25-50 cc po when offered each feed. Took 33% po on % po on % po on , Voiding. Stooling. Wt 2365 grams (up 10).\n\nHad family meeting with both parents, , RN and myself yesterday. They are very anxious to take him home. We agreed that he would be ready for d/c when he consistently takes 100cc/kg to ensure adequate hydration. Close f/u will be needed by Dr. (pediatrician) and VNA will be needed.\n\nA: Stable. Needs to work on feeds. Murmur to be evaluated.\n\nP: Monitor.\n Preliminary w/u for murmur\n Encourage pos\n Contact Dr. today re plan\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-01 00:00:00.000", "description": "Report", "row_id": 1703061, "text": "Newborn Med Attending\n\nDOL#11. Cont in RA. No spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2550 up 5, on 120 cc/kg/d E20.\nA/P: Infant s/p RDS and air leak now working up PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2186-01-01 00:00:00.000", "description": "Report", "row_id": 1703062, "text": "NICU Nursing Progress Note\n\nRESP\nO: Baseline subcostal retractions noted. O2 sats above 95.\nA; No evidence of compromise.\nP: Monitor and assess.\n\nNUTRITION\nO: Wakes occasionally for feeds. Bottle feeds with volufeed\nand yellow nipple and does not demonstrate vigorous\nsustained sucking nor does he consistently take minimum\nrequirement po. Gavage supplemented for remainder. Abd exam\nbenign. Voiding and stooling.\nA: Slow to learn po feeding.\nP; Continue to attempt po as tol.\n\nDEVELOPMENT\nO: Temp stable in open crib. opens eyes for brief periods in\nresponse to voices.\nA; Appropraite behavior.\nP; Support development.\n\nPARENTING\nO: Dad called for update and progress report given. Parents\nin at this time for infant's feeding.\nA; Invovled parents.\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-02 00:00:00.000", "description": "Report", "row_id": 1703063, "text": "NPN\n\n\n#2-O: In ra , RR 40's-60's, clear and equal, pink , sats\n99-100 consistently. no issues.\n\n#3-O; on 120cc/k/d full enteral feeds of E20 = 51cc q4 hrs,\npo/pg, taking 20-30po fair, pg for remainders. Attempting\npo's q feed. Needs encouragement but tires easily.\n\n#4-O; temp stable in crib, alert and active, afof, poor po\nfeeder.\n\n#5-O; parents called x 2 , updated, anxious to take \nhome, requesting family meeting today around 4 pm to discuss\nfeeding issues and plans for discharge.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-02 00:00:00.000", "description": "Report", "row_id": 1703064, "text": "Neonatology Attending\n\nDOL 12 CGA 37 week\n\nStable in RA.\n\nBP 85/47 mean 64\n\nOn 120 cc/kg/d E 20 po/pg. ~ po. Voiding. Stooling. Wt 2355 grams (down 190).\n\nParents want family meeting today. Want to go home.\n\nA: Stable. Still learning to feed.\n\nP: Encourage pos\n Family meeting today\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-03 00:00:00.000", "description": "Report", "row_id": 1703069, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, alert in an oepn crib, AFOF, sutures opposed, good . BBS clear and equal with good air entry. Gr murmur over LLSB, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2186-01-03 00:00:00.000", "description": "Report", "row_id": 1703070, "text": "Nursing Progress Notes.\n\n\n#2 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, sats 96 to 100%. No spells noted\nto time of report. A: Doing well in room air. P: Resolve\nproblem.\n#3 O: Total fluids decreased to 100cc/kg/day. Feeds offered\nby bottle. Feeds taken well initially and then baby tires\nout. Baby has met his minimum so far. Abdomen benign,\nvoiding well, no stool yet today. A: PO feeding a little\nbetter today. P: Continue to follow feeding trend and\nweight gain.\n#4 O: Temp stable in open crib. Baby is and active\nduring cares and tires out during feeding. Baby sleeps well\nbetween feeds. Baby woke on his own for 1 feeding. A:\nAppropriate for age. P: Continue to support development.\n#5 O: Parents called and came in to visit this afternoon.\nA: Involved family. P: Continue to keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-02 00:00:00.000", "description": "Report", "row_id": 1703065, "text": "Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\nretractions noted so far this shift. P cont to assess resp\nneeds.\n3. FEN O/A TF= 120cc/kg/day of E20. Inf offered PO each\nfeed. This shift, inf taking volume, remainder gavaged.\n Tol well. No spits, Max asp 1cc. Belly soft, no loops.\nVoiding, Stooling. P Cont to offer PO feeds, cont to assess\nFEN needs.\n4. DEV O/A remains in as open crib with stable temp.\n A/A w/cares. Inf not waking for feeds. Inf able to bring\nhands to mouth to calm self. P cont to assess dev needs.\n5. Parents O/A Mom in at 10:00 AM for the day, for cares\nand visits. Updates given. P Fam meeting planned for later\nthis afternoon. Cont to support, enc calls and visits.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-01-02 00:00:00.000", "description": "Report", "row_id": 1703066, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, alert, AFOF, sutures opposed, good . BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n\nFamily meeting today with parents, RN, attending, . Discussed feeding issues. Plan to assess his intake over the next couple of days. Parents expressing concerns and understand need for to be taking in enough volume po to prevent dehydration.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703018, "text": "NICU NPN 1900-0700\n\n\n#1 POT FOR SEPSIS O: Baby remains on ampicillin, and gent,\nfor a 7d course. BC neg to date.\n\n#2 RESP O: Baby remains orally intubated on HFOV, remains on\nsettings of MAP8, Delta P 17, Hz 15. No changes made\novernight.Capillary gas a 3am 7.29/58/44/29/0. Fio2 35-40%\ntonight. RR 50-70's, with baseline mild ic/sc retractions.\nLungs coarse, clearer after sucitoning. O2 sats 93-98%, no\ndrifts, no bradys. Infant has a right chest tube to constant\nsuction, with air bubbles noted in chamber. Small amt of\nserosangrenous drainage noted from CT. Dressing over\ninsertion site intact and clean.\n\n#3 FEN O: Tf remain at 60cc/k/d. Baby remains npo, d stick\n76. Voiding, no stool to time this shift. IVF of D10PN, and\nIL, are infusing through PIV well. Abdominal exam benign.\n\n#4 DEV O: Baby is active, opens eyes with cares, settles\nafter cares, receiving MSO4 q4hr, which appears to aid in\ncomfort of baby. are soft and flat.\n\n#5 Parenting O: Parents in x2 during the evening, asking\nappropriate questions. Both very loving towards infant.\nUpdate given at bedside.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703019, "text": "Respiratory Care Note\nPt. continues on HFOV MAP 8 Amp 17 and FIO2 35-40% FIO2. BS coarse. Pt. sx'd for mod. white secretions. Gas obtained. No changes made at this time. Pt. flipped at 2200. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703020, "text": "Neonatology NP Note\nPE: nested on open warmer, on HFOV, sedated,quiet but with some activity during exam, 1/2 hour post morphine administration,AFOf,, mild subcostal retractions, lungs cl/= with good air entry bilaterally, chest tube with intact dressing, pleurevac still with continuous bubbling, RRR, no murmur, pink and well perfused, jaundice, abdomen soft, non tender and without loops.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-24 00:00:00.000", "description": "Report", "row_id": 1703021, "text": "NICU Attending Note\n\nDOL # 3 for this former 35 week gestation male with HMD, PTX, presumed pneumonia.\n\nAgree with detailed .\n\nCVR/RESP: No murmur, negative cardiac eval yesterday, remains on MAP 8, delta P 17, FiO2 37%, Most recent CBG: 7.29/58. Right sided chest tube still bubbling. Will check CXR 24 hours after last to ensure no collapse on low MAP, otherwise continue current maangement.\n\nBILI: 7.2, will follow clinically.\n\nFEN: Weight today 2460 gm, down 85 gm since birth, on 60 cc/kg/d, PN/IL, D stick WNL, u/o 3 cc/kg/hr. Will continue NPO while resp status unstable.\n\nID: On amp and gent day . Gent levels to be sent today. WIll complete 7 day course of antibiotics for presumed sepsis/pneumonia. LP when able to tolerate.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703011, "text": " On-call/Incidental Note\nCalled to bedside for increased work of breathing and O2 desaturation. Decreased breath sounds on right. Transillumination significant on right suggesting large pneumothorax. Infant cardiovascularly stable with mean BP 45, FiO2 .40. Chest x-ray obtained and confirmed large right pneumothorax. Fentanyl 5 mcg IV given. Right chest needled with 23g butterfly needle for 40 cc air initially, then continuous leak. Decision made to give trial on HFOV. Chest needled with 22g Angiocath for continous leak of air. Decision made to place chest tube. Mother notified in her room in person by Dr. .\n\n\nChest tube procedure note\n\nInfant positioned right side up, prepped and draped in sterile fashion. Incision made ~ 5th intercostal space, mid-axillary line. Pleural space entered at 4th intercostal space. #10 Fr. tube passed cephalad/anterior with return of air and sero-sanguinous fluid. Sutured in place at 3.75 cm mark with 3.0 silk. Vaseline guaze and occlusive dressing applied. Chest x-ray shows total resolution of right pneumothorax, tip of tube high in chest, pulled back .5 cm. Additional dose of Morphine, 0.25 mg IV given and local anesthesia with 1% Lidocine. Infant tolerated procedure well. No complications.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703014, "text": "Neonatology\nREquired reintubation yesterday evening. Given surfactanct. Early this am developed right sided ptx. Mainatined sats and BP with ptx. required inc O2.Attempted needle thoracentesis which lead to continuous leak. Attempted another thoracentesis while on HFOV but had persistent leak. CT placed with CXR resolution of ptx. Weaned on O2 and delat P over course of day. Pain control with systemic narcotiic. Spoke to mother this am and she has visited. Heart size remains increased on CXR. No murmur. WIll do hyperoxia test with TCOM. Max pO2 Heart size may be related to infection. Continue on CT suction for today.\n\nWt 2535. TF at 60 cc/k/d. Will continue there. Abdomen bneign. Feeds had been attempted yesterday. Lytes to be checked.\n\nON abx. Plan for at least 7 day course. WIll check repeat CBC today.\n\nSpoke with mother at and in her room.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703015, "text": "Clinical Nutrition:\nO:\nFormer 35 weeker, BB now on DoL #2\nMaternal history/delivery reviewed.\nBirth wt: 2535g (25-50th%ile)\nBirth LN: 47.5cm (~50th%ile)\nBirth HC: 32.5cm (~50th%ile)\nLabs: 24hr lytes noted\nDsticks: 70-101 this am\nTF: 60 cc/kg/day\nAccess: PIV\nNutrition: NPO/Pn&IL (D10, 2.5g% AA & 1 g/kg of lipid)\nProjected 24hr nutrition: 34 Kcals/kg, 1.5 g/kg of AA\nGI: benign; x2 large spits noted early this am\n\nA/goals:\nS/P chest tube placement for pneumothorax, made NPO last evening for increased WOB. To start PN today via PIV. 24 hr lytes are wnl. Dsticks are stable on D10 IVF. GI exam is benign, voiding & stooling g- & 2 lg spits noted early this morning probably d/t stress. be able to re-trial enteral feeds this weekend if continues to improve. PN/IL goals: 90-110 Kcals/kg, 3 g/kg of AA & 3 g/kg of IL. Growth goals: ~15 g/kg/day, ~0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN once at goal volume feeds. Will cont. to follow w/team & participate in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703016, "text": " Physical Exam\n\nPE: pink, well perfused, active, sm AF, sutures approximated, orally intubated, being hand bagged during exam, breath sounds clear/equal with fair to good air entry, mild retracting, spontaneous respirations, right chest tube in place, no murmur, +2/= pulses, abd soft, non distended, + bowel sounds, no rashes, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2185-12-23 00:00:00.000", "description": "Report", "row_id": 1703017, "text": "NPN 0700-1900\n\n#1 Possible Sepsis\nO: Remains on Amp. and Gent. Temps and VS stable and WNL. Alert with cares, morphine for pain. Appropriate and color. Repeat CBC today WBC-16.1, HCT-40.5 Plates-306 Diff pending.\nA: Possible Sepsis\nP: Minimum 7 day course antibiotics. Will need LP when more stable resp. status.\n\n#2 Alt. in Resp. Function\nO: Infant remains on ventilator, 3.5 oral EET, current settings MAP-8 Delta P-17 (weaned from 18 after cap gas, see flow sheet for results) Hertz-15. 02 need 36-40% to keep sats 94-99. Breath sounds are clear bilat. Infant breathing above vent. Initially RR 60's-70's. Presently 50's-60's. Mild IC/SC retractions remain. Suctioned X 1 for mod. tan secretions. R CT to constant suction with mod. amt. air bubbles noted in chamber and ~5cc serosanguinous drainange collected. Cardiac w/u with EKG and hyperoxia test neg. for cadiac disease.\nA: 35 wk infant with surfactant defficiency and air leak, stable on with CT\nP: Continue close observation and monitoring. Follow cap gases and wean vent as able.\n\n#3 Alt. in Nutrition\nO: NPO. PIV changed from D10W/2NaCl at 60cc/kg to PND10 + IL at 1800. TF remain at 60cc/kg= PN at 5.8cc/hr + IL at .5cc/hr. Todays lab results Na-137 K-4.1 Cl-102 CO2-20 Bili-7.2 BUN-16 Creat.-.5. D/S=102. Abd. is flat, soft with + BS. Voiding 2.6cc/kg/hr for past 12 hrs. No stools.\nA: Adequate Hydration\nP: Continue NPO. Follow D/S, electrolytes and daily wts.\n\n#4 Alt. in Development\nO: Temps stable on servo warmer, nested in sheepskin, postioned supine with boundaries in place. Rotated 180 degrees X 1. Medicated with morphine Q 4 hrs for CT pain with good effect. Sleeping well between interventions. Alert when disturbed.\nA: Apporpriate behaviors for GA, adequate pain management\nP: Continue with present interventions. Close assessment of pain. Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: Mom up several times. Updated Q time by this RN. Mom also spoke with and RT. Dad called X 1 and visited X 1. Also updated and questions answered. Parents are spending the night in the parent room on PP floor and plan to visit later this PM.\nA: Involved, loving parents\nP: Keep informed and support.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-26 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 781098, "text": " 9:44 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: r/o residual ptx. Following lung expansion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, Ptx, s/p chest tube now to water seal\n REASON FOR THIS EXAMINATION:\n r/o residual ptx. Following lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 5 day old boy with hyaline membrane disease, status post right\n pneumothorax and chest tube placement. Chest tube has now been placed to\n waterseal.\n\n PORTABLE CHEST: Comparison is made to previous films from and .\n\n FINDINGS: Again seen is an endotracheal tube with the tip about way\n between the thoracic inlet and carina with the patient's head turned towards\n the left. There is a right chest tube with the tip projected over the upper\n thorax. A side port appears to be located at the margin of the chest wall.\n Again seen is hyperlucency along the right cardiac border and in the right\n supradiaphragmatic region, which is consistent with residual pneumothorax,\n likely small. This has not changed substantially. The patient is rotated\n towards the left. Continued improvement in bilateral, diffuse, hazy,\n pulmonary parenchymal opacities, consistent with evolution of hyaline membrane\n disease. The cardiothymic silhouette is within normal limits. The bony thorax\n appears to be intact. The visualized bowel gas pattern is unremarkable.\n\n IMPRESSION:\n\n 1. Small, residual right pneumothorax with right chest tube in place. This\n has not changed substantially.\n\n 2. Findings consistent with evolution of hyaline membrane disease.\n\n 3. Slightly low positioning of endotracheal tube.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-12-21 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 780701, "text": " 11:23 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: check ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with rds\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST: Since our exam earlier today the patient has been intubated. The\n endotracheal tube ends at the thoracic inlet. The lung volumes are slightly\n improved and the lungs are slightly clear. The findings continue to be\n compatible with hilan membrane disease.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-23 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 780821, "text": " 5:47 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: s/p chest tube placement for ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n s/p chest tube placement for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Post chest tube placement for a pneumothorax.\n\n PORTABLE CHEST: In followup to earlier on , a right chest tube has\n been advanced with near complete resolution of the pneumothorax with some\n persistent lucency in the right cardiophrenic region, likely a component of\n the pneumothorax anteriorly. There is improved aeration of both lungs which\n are now hyperinflated with a diffuse mixed hazy and interstitial pattern in\n keeping with RDS or edema. The heart remains enlarged in size. Pulmonary\n blood flow is difficult to assess but appears fairly normal and symmetric. No\n significant pleural fluid collections. The patient remains intubated with ETT\n in satisfactory position with the neck extended.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-23 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 780817, "text": " 4:42 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lungs, ? right pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS\n REASON FOR THIS EXAMINATION:\n evaluate lungs\n ? right pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 4:45 HOURS:\n\n HISTORY: RDS. Question pneumothorax.\n\n In follow up to earlier on , there is now a large pneumothorax causing\n compressive atelectasis of the right lung and causing some mediastinal shift\n to the left and depression of the right hemidiaphragm in keeping with the\n degree of tension. The patient is intubated with ETT at the mid thoracic\n trachea with the neck partially flexed. Diffuse alveolar opacity is present\n throughout the left lung.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-24 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 780967, "text": " 4:23 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: assess pneumothorax and lung expansion on HFOV\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with right thoracotomy tube\n REASON FOR THIS EXAMINATION:\n assess pneumothorax and lung expansion on HFOV\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right thoracosotomy tube. Assess for pneumothorax and lung\n expansion.\n\n COMMENT: The right sided chest tube has been withdrawn partially and a side\n hole lies outside the rib cage. There is a small right basal and anterior\n pneumothorax, which appears more prominent than comparison to the prior study.\n Persistent left lower lobe retrocardiac alveolar opacities noted, with an\n associated air bronchogram, without significant change from the prior study.\n This may represent subsegmental atelectasis or pneumonia. A new left\n pneumothorax is present compared to the prior study from . The\n findings were discussed with a clinical team at the time of this exam.\n\n The endotracheal tube is located an inch above the carina. The bowel gas\n pattern appears unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-21 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 780689, "text": " 6:48 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: evaluate lung \n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant grunting, flaring and retraction\n REASON FOR THIS EXAMINATION:\n evaluate lung \n ______________________________________________________________________________\n FINAL REPORT\n This appears to be our initial exam on this newborn infant with respiratory\n distress.\n\n The lung volumes are quite low and the lungs are diffusely hazy. The findings\n are compatible with hyaline membrane disease.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-22 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 780800, "text": " 8:58 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lungs; ? ETT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress; asymmetric chest movement; re-intubated after\n trial of CPAP\n REASON FOR THIS EXAMINATION:\n evaluate lungs; ? ETT position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with respiratory distress, asymmetric chest movement,\n reintubated after a trial of CPAP.\n\n ET tube is 5 mm aove the carina. There is a moderate-sized right\n pneumothorax. There is a mediastinal shift to the left. Both lungs are\n diffusely opacified consistent with hyaline membrane disease.\n\n IMPRESSION: New right tension pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2185-12-22 00:00:00.000", "description": "Report", "row_id": 167587, "text": "Normal sinus rhythm. Within normal limits for age.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2109-08-04 00:00:00.000", "description": "Report", "row_id": 1374796, "text": "Adm Note\nO: Pt 70 yo female w hx cva,chf permanent trach x ? yrs, niddm.Presented to ew w resp distress & partial trach obstruction. Per pt she reports limited to no home humidification through trach d/t limited energy source to run compressor for humidification and air conditioning concomittently. Initial abg on adm po2 63,pco2 100 ph 7.20 w ambuing on 100%. Pt trach changed in ew for obstruction from #7 shiley to 4 shiley (after several attempts to place larger size trach unsuccessful).\n Serum K+ 7.0 on adm & lr x 1 liter w K+ dwn to 6.0.? glucose. See carevue for other lab results.\n\nCV status: sr w bbb rate 60's . SBP 110-130 range.\n\nResp status: Bilat brth snds cl but distant to coarse ^ lobes.O2 sat 97-99% on 60% tv 600 rr 12 peep 5. Pip 30-35. Lavaged and suctioned for bldy drng & sent for sput c/s.\n\nGi status: ngt placed via rt nares position confirmed & drained coffee grnd.Position confirmed.Abd tender esp at ruq.\n\nGu status: Foley #18 fr.placed & drained 400cc cl pale yellow urine.\n\nNeuro status:Briefly lethargic on adm( as reported in ew to alert, following simple commands. bilat grasp 3+ . Moving bilat lower extrems on bed.\n\nHeme/Id/Endo: cbc,lft's, chem 7 ck w mb & troponin level tsh, theoph levels sent & results pending.\n\nA/P: Adm to csru on micu team. Micu team here to w/u and orders in progress.\n Check labs, ? fld resusc .Reassess hyperkalemia\n" }, { "category": "Nursing/other", "chartdate": "2109-08-05 00:00:00.000", "description": "Report", "row_id": 1374797, "text": "Respiratory Care:\n\nPatient trached with 4.0 shiley trach. Vent settings Vt 600, A/c 8, Fio2 50%, and peep 5. PAP/Plateau 29/24. Bs slightly coarse bilaterally. Sx'd for sm amount of thick blood tinges sputum. A/C rate weaned to 8. Fio2 weaned to 50%. Adequate Abg. See Carevue for results. Plan to wean to Psv as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-05 00:00:00.000", "description": "Report", "row_id": 1374798, "text": "NEUROLOGICALLY INTACT. WAS LETHARGIC WHEN HER GLUCOSE WAS 59. AFTER BEING TREATED WITH D50, SHE WAS MUCH MORE ALERT AND ORIENTED. ON CMV OVER NIGHT METABOLIC ALKALOSIS IMROVED WITH VENT CHANGES. PRESENTLY VENTED ON 600TV, RR 8 PEEP5 PS5. IT IS BELIEVED THAT PT'S BASELINE CO2 IS IN THE 50'S. SUCTIONED WITH A #10 SUCTION CATHETER FOR THICK SMALL AMOUNTS OF BLOOD TINGED. LUNGS SOUND CLEAR. COUGHING AND RAISING AS WELL. NSR NO ECTOPY. ALINE PLACED. GIVEN D50 AND CAGLUC. TO REPLACE LOW LEVELS. FOLEY DRAINING GOOD AMOUNTS OF CLEAR YELLOW URINE. PAN CULTURED. PCXR DONE THIS AM. RUQ PAIN ON PALPATION. N/C VOICED. PLAN TO WEAN OFF THE VENT., MONITOR LABS AND I/O'S. ? IVF AT SOME POINT.\n" }, { "category": "ECG", "chartdate": "2109-08-05 00:00:00.000", "description": "Report", "row_id": 279416, "text": "Sinus rhythm, rate 66\nMultiple atrial premature complexes\nBifascicular Block: Right bundle branch block and left anterior fascicular\nblock\nPoor R wave progression\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2109-08-04 00:00:00.000", "description": "Report", "row_id": 279417, "text": "Sinus rhythm. Biatrial abnormality. Right bundle-branch block. T wave\ninversions with slight ST segment depressions in leads V2-V5 possibly\nconsistent with anterior wall ischemia. Compared to the previous tracing\nof the axis is slightly more rightward. Otherwise, no significant\nchange. Clinical correlation is suggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-08-08 00:00:00.000", "description": "Report", "row_id": 1374813, "text": "CSRU TRANFER NOTE\n\nPlease refer to CSRU Transfer Note from for details of PMH and current hospital treatment.\n\nCurrent ROS\n\nNeuro: Alert and appropriate in interactions. MAE with good strength.\n\nCV: HR mainly 70's NSR. Noted to have frequent blocked APC's followed by junctional escape beats. BP 100-120/50-70. Pt without c/o. MD aware. Ok to continue with Diltiazem MD. K+ 3.7. Cont's on Coumadin. Am PT/INR 20.8/2.2. Hct 49.7.\n\nResp: BS clear this am, diminished aeration at bases. Cont's on 50% trach mask with O2 sats 90% or greater. Cont's to be able to cough secretions up most of time. Will occasionally use suction catheter inserted just inside trach to help pt clear secretions. Secretions pale yellow, slightly blood tinged at times, thick. Still with some discomfort at trach site d/t trach replacement. Trach cuff down.\n\nGI/GU: + BS. ABD obese. No evidence of abd pain with palpation this am. Tolerating po's in good amts without signs of aspiration. BM . Voiding on commode. BUN/Cr 12/1.0.\n\nEndo: Cont's on SSRI as ordered.\n\nSkin: Intact to back/buttocks/groin areas.\n\nActivity: OOB to chair w/ assist of 1 this am. Tolerates well. Waiting for PT eval.\n\nA/P Increased frequency of blocked APC's with stable BP. Cont to monitor. Cont Diltiazem. Coumadin per team. Monitor INR. Suction trach prn. Monitor O2 sats. FS QID. ? restart po Glucotrol soon. PT eval to increase activity. Case management to plan for discharge needs. Transfer to floor today when bed available.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-08-06 00:00:00.000", "description": "Report", "row_id": 1374806, "text": "Respiratory Care\n spent most of the day on AC 500 x 8, 50% % PEEP. Trached changed from #4 shiley to #6 with some dilitation needed, otherwise no complications. After some sedation wore off was placed on trach mask 40%. BS slighlty coarse yet equal. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-07 00:00:00.000", "description": "Report", "row_id": 1374807, "text": "MICU PROGRESS\nREMAINS OFF VENT - ON 50 % TRACH MASK ALL NOC. AM ABG'S IN LINE W/ PREVIOUS RESULTS. SUCTIONED SEVERAL TIMES FOR THICK TO THIN BLOOD TINGED. NGT CLAMPED ALL NOC, - PUT TO SUCTION THIS AM - MIN NG OUT. PT SOFT SOLID PO'S DURING EVE. PT SLEPT WELL. SEE FLOW SHEET FOR ADDITIONAL INFO. PT TO BE TRANSFERRED TO FLOOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-07 00:00:00.000", "description": "Report", "row_id": 1374808, "text": "CSRU TRANSFER NOTE\n\nPt is a 70 year old woman who presented to EW with increasing somnolence and resp distress. At home, pt had not been using humidification for her oxygen due to fear of overloading her electrical while using air conditioning in hot humid weather. She was also expieriencing RUQ pain with eating and had decreased her po intake. Right shoulder pain also a complaint. When evaluated in EW, unable to pass suction catheter--lavaged and suctioned w/ difficulty for thick, green sputum plug. Had presented w/ # 7 portex trach (since ' d/t OSA) which was changed to #4 shiley cuffed. ABG 7.24/100/63. Placed on ventilator d/t resp faillure and transfered to CSRU.\n\nNKDA\n\nPMH: Morbid obesity, NIDDM, CHF, CVA '--with right sided weakness, OSA-trach with home oxygen at 6l, polycythemia, pulmonary htn, osteoarthritis, h/o afib/flutter-ablation in .\n\nMeds at home KCL, Lasix, Theophylline, Diltiazem, Coumadin, Glucotrol, Metolazone.\n\nNeuro: Initially very lethargic but would always be able to respond. Lethargy has improved over last several days. Pt seems slightly hard of hearing. Able to MAE with minimal if any notable right sided weakness. PERRL. Attempts to communicate with mouthing words. Head CT on day of admission r/o'd intracranial process d/t elevated INR of 13.5.\n\nCV: HR 70's NSR, occasionally in 60's. Episodes of frequent APC's. BP 130-150/60's by aline, 110-120/40's by cuff. Hct in high 40's . Skin warm, dry. + PP bilat. Restarted coumadin -PT 18.1, PTT 38.5/ INR 2.2 this am.\n\nResp: BS with intermittant rhonchi throughout, diminished aeration to bases, ? faint rales at left base this morning. Trach changed to #6 fenestrated shiley with cuff up yesterday after dilatation. Trach area remains sore d/t manipulation. Cough is strong and patient is able to cough secretions out or atleast to upper part of trach much of time. Secretions blood tinged this am with deep suctioning-pulmonary fellow aware. Will cont to monitor. ABG this morning on 50% trach mask 62/62/7.35/36/90% within parameters by team. O2 sats 90-94%- >greater than 89% acceptable per team.\n\nGI/GU: Abd obese, soft. Still with c/o RUQ/epigastric pain mainly w/ palpation but intermittantly without manipulation. LFT's WNL. Plan per team is to monitor clinically. NGT currently in place, clamped-? d/c today. Started taking soft diet after trach change yesterday without difficulty. Does have some difficulty swallowing d/t pain at trach site but had breakfast without signs of aspiration. u/o adequate. Hydrated over last 2 days w/ IVF. BUN/Cr 12/0.8 (baseline Cr 1.2-1.8). No BM yet.\n\nEndo: BS initially in 50's requiring treatment w/ D50. Have improved w/ IVF of D%1/2 NS. Covered w/ SSRI as ordered.\n\nID: Afebrile. WBC wnl. Levaquin empirically. Cx's pnd.\n\nSkin: No breakdown.\n\nActivity: OOB to chair w/ 2 assist and tolerated well.. Normally walked with walker at home. PT consult ordered.\n\nSocial: Lives with caret\n" }, { "category": "Nursing/other", "chartdate": "2109-08-07 00:00:00.000", "description": "Report", "row_id": 1374809, "text": "(Continued)\n in . Siblings have been into visit.\n\nA/P Improved neuro status. Hemodynamically stable. Able to mobilize secretions better with larger sized trach. Suction prn but encourage pt to cough to clear secretions. Monitor for increase in blood tinged secretions, especially with restart of Coumadin. Encourage po intake, monitor for aspiration. Monitor abd pain. Check cultures. Increase activity as tolerated. ? rehab stay prior to discharge home. PT consult ordered. ? transfer to floor today pnd MICU team orders.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-07 00:00:00.000", "description": "Report", "row_id": 1374810, "text": "Transfer Note Addendum\n\nGU: u/o < 30cc/hr x 2 hours. Still with only min po fluid intake. Team aware. IVF at 100cc/hr initiated.\n\nResp: Trach cuff deflated MD order. To remain deflated w/ meals. No signs of aspiration with lunch.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-07 00:00:00.000", "description": "Report", "row_id": 1374811, "text": "Update\nNo bed available to transfer to from the ICU. Dr. here to accept pt as a floor patient but pt will remain in the ICU till bed available. IV fluids dc'd. Pt taking fluids by mouth with trach cuff down. Pt took some solid food with dinner tray. OOB to chair throughout the day. Assisted to commode x 2. Pt states that she helps herself at home but uses as walker. She mentioned that she has a walker with worn rubber tips on it. Can we get these here at the hospital. Her walker is at home at this time. Pt states that she moved her bowels earlier (her sister helped her). Her second session on the commode produced ~5cc brown mucous only. Coughing and raising white to tan secretions from tracheostomy. Trach sponges changed. Foley cath dc'd @ 2130 (dtv @ 0530). Possible discharge to home within 48/hrs. Plan to continue to monitor airway for patency and cough for secretions.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-08 00:00:00.000", "description": "Report", "row_id": 1374812, "text": "update\nO: SLEPT SOUNDLY UNTIL~0400. BEGAN TO C&R SM AMT THICK,BLOOD-TINGED SPUTUM ONCE AWAKE BUT REQUIRED SHALLOW SUX OF TRACH TO CLEAR. SPO2 IMPROVED FROM 90-94% AFTER. HR NSR W/ OCC SB AND JUNCTIONAL ESCAPE BEAT, THEN RETURN TO NSR. BP STABLE BY CUFF. VOIDED 250ML CLR YELOW URINE ON BEDPAN. PT BATHED AND NOW BACK TO SLEEP. VS CHECKED Q 2 HRS.\nA: STABLE, RESTING WELL. STRONG COUGH BUT OCC NEEDS SUX HELP TO RAISE SECRETIONS FULLY.\nP: CONT TO MONITOR OXYGENATION AND SECRETIONS CLOSELY. ADV DIET AND ACTIVITY AS . TRANSFER TO FLOOR WHEN BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-06 00:00:00.000", "description": "Report", "row_id": 1374804, "text": "NPN\n\nNeuro: Seems slightly more lethargic this morning as compared to yesterday afternoon. Easily awakens to voice. MAE to request, right leg slightly weaker than left.\n\nCV: HR mostly 60's NSR, occasionally noted to be in high 50's SB. Occas APC's, rare PVC noted. BP 120-13's/60's with MAP's 70-80. Hct 47.2. PT 17.1 with INR 1.9. Skin warm, dry. Cont's w/ D51/2 NS at 100cc/hr.\n\nResp: BS w/ intermittant rhonchi which clear with suctioning of thick yellow secretions. Lavaged w/ suctioning prn. Cont's on AC 500x8, 50% FiO2 with stable ABG this am. Occas 1-2 breaths above vent. O2 sats 89-93%. Episode of O2 sat of 89% which improved w/ suctioning. Plan to change to larger trach today.\n\nGI/GU: Abd large, soft. Still c/o RUQ/epigastric abd pain mainly w/ palpation although she states she has dull throbbing pain intermittantly. Hypoactive BS. NGT w/ brown dng. No BM. u/o adequate. BUN/Cr 28/1.2\n\nEndo: Received 2 u SC insulin for glucose of 155 this am.\n\nID: Afebrile. Cultures pnd. WBC 6.7.\n\nSkin: Intact.\n\nA/P Lethargic but responsive to voice. Hemodynamically stable. Hct down slightly from yesterday. Plan to change trach and ?start to wean off vent. Suction prn for thick secretions. O2 sats stable at 89% or greater. Still w/ abd pain, LFT's wnl. Will cont to monitor. Bun/Cr decreasing. Glucose with less episodes of hypoglycemia. Cont to monitor and treat w/ SSRI as ordered. ? start TF's after trach change. Check cultures.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-08-06 00:00:00.000", "description": "Report", "row_id": 1374805, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: PT. FOLLOWING COMMANDS, STILL C/O DIFFUSE GENERAL ABD. DISCOMFORT. SEDATED WITH VERSED, FENTANYL AND PROPOFOL GTT FOR TRACH CHANGE, EASILY AROUSABLE AFTER 30\" AND APPROPRIATELY FOLLOWING COMMANDS AGAIN. OOB TO CHAIR WITH ASSIST X2 VERY STEADY ON FEET.\nCARDIAC: CONT. TO BE IN NSR WITH OCCAS. PAC'S. SYS B/P >130'S AND MAP >80 VIA R RAD ALINE. 2 PERIPH IV'S INTACT, WITH MAINT. FLUID OF D5 W/20K AT 100CC/HR.\nRESP: BS COARSE THRU-OUT, AMBUED AND SUCTIONED FOR THICK WHITISH SECREATIONS. TRACH CHANGED BY PULM. TEAM WITH ANESTHESIA STANDING BY, NEW # 6 SHILEY TRACH INSERTED WITHOUT DIFFICULTY, PLACED ON 80% FIO2 VIA VENT FOR PROCEDURE. AFTER PT. AWAKENING FULLY, ABLE TO GET PT. OOB TO CHAIR WITH ASSIST X2 AND PLACE PT. ON TRACH COLLAR WITH FIO2 OF 50%, MAINTAINING SAT'S 89-93%. WILL PLAN TO CHECK ABG.\nGI/GU: HOURLY URINES CONT. TO BE >25CC. + BS THRU-OUT, WILL TRY PT. ON MECH. SOFT DIET AFTER SHE IS ON TRACH COLLAR. CONT. TO MONITOR BS AND TREAT WITH S.S. INSULIN.\nPLAN: CONT. TO VENT WEAN AS TOLERATED TO TRACH COLLAR. MONITOR RESP. STATUS CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-05 00:00:00.000", "description": "Report", "row_id": 1374799, "text": "NPN\n\nNeuro: Easily awakens to voice but is sleeping when not stimulated. Follows commands without difficulty. PERRL. Extremities with good strength. Mouthing requests to communicate needs.\n\nCV: HR 70's NSR, BBB on ECG. Episode of frequent APC's this morning which resolved spontaneously. SBP 120's with MAP 80-90. CPK 53 this am. Skin warm, dry. Diltiazem changed from sustained release to regular release q 6 hours. Coags decreased after Vit K last evening. INR 3.2 Hct 48.6. K+ 4.6.\n\nResp: BS initially rhonchorous in upper lobes bilat, diminished at bases. Suctioned for thick, yellow, blood tinged secretions after lavage. Cough is strong and does allow pt to cough up secretions. Remains on AC 600x8, 5 peep, 50% FiO2. Rarely breathing over vent and only when more alert. O2 sats 91-93%, up to 95-96% w/ suctioning. Decision to leave #4 shiley in place to allow for removal of inner cannula for cleaning.\n\nGI/GU: Abd obese, soft. c/o abd pain with palpation of right upper quadrant/epigastric areas. OGT w/ brown dng. u/o 30-60cc/hr. BUN/Cr 44/1.5. No BM thus far.\n\nEndo: FS 119 after D50 this am. FS 74 at 1000. Remains NPO.\n\nID: Afebrile. WBC 5.4. Cultures pnd.\n\nSkin: No breakdown noted to back/buttocks.\n\nA/P Hemodynamically stable. Coags improved. Remains lethargic but arousable to voice. Is not breathing over vent at this time. ? attempt weaning today-awaiting MICU team orders. U/O stable. Monitor glucose levels closely. Check cultures and monitor WBC.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-05 00:00:00.000", "description": "Report", "row_id": 1374800, "text": "NPN Addendum\n\nO2 sats down to 89% this afternoon despite suctioning. Pt without c/o difficulty breathing. Team aware. ABG 60/61/7.35/35/90%. No changes in vent d/t stable ABG. O2 sats fluctuating between 89-93%. Pulmonary fellow attempted to change trach to #8 portex without success. Noted to have blood tinged secretions after manipulation. Will attempt again with smaller trach.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-05 00:00:00.000", "description": "Report", "row_id": 1374801, "text": "Resp Care\nremains vented on ac mode...appears comfortable. pulmonary attempted to change trach to a #8.0...unable. #6 shiley ordered...pulmonary will return tomorrow. frequent suctioning for thick bld tinged sputum. (bld tinged after trach change). plan is to wean after trach is changed however could be on a spont mode.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-06 00:00:00.000", "description": "Report", "row_id": 1374802, "text": "Respiratory Care:\n\nPatient trached with 4.0 shiley trach. Vent settings Vt 500, A/c 8, Fio2 50%, and Peep 5. PAP/Plateau 28/24. Bs coarse bilaterally. Sx'/lavaged for sm amount of thick blood tinged sputum. Abg on above settings PaO2 63, PaC02 59, PH 7.36. Co2 retainer at baseline. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2109-08-06 00:00:00.000", "description": "Report", "row_id": 1374803, "text": "MICU UPDATE\nNEURO: AWAKE AND ALERT. SLEPT OVERNIGHT. APPROPRIATE. MAE.\n\nPULM: REMAINS VENTED - NO CHANGES MADE OVERNIGHT. SUCTIONED SEVERAL TIMES FOR THICK OLD BLD. TRACH TO BE CHANGED TODAY.\n\nCARD: HR SR W/ PAC'S. BP STABLE - SEE FLOW SHEET.\n\nGI: OGT TO LCWS - DRNG BILIOUS.\n\nGU: QS UOP - AMBER.\n\nSKIN: INTACT. TURNED Q 3-4 HR\n\nMISC: EXPECT TO CHANGE TRACH TADAY. ? TRANSFER TO MICU.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2106-02-07 00:00:00.000", "description": "Report", "row_id": 1275815, "text": "CCU NURSING 0700-1900 ISCHEMIC COLITIS\nS. \"MY RIGHT KNEE HURTS!\"\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: AFEB - WBC'S UP TO 55 CONTINUES ON PIPERACILLIN/FLAGYL\n\nCV: HR 100-111 ST, NO VEA, MGSO4 2 GM, CA GLUC 3GM GIVEN TO REPLACE LYTES, BP STABLE 111-124/50-60'S\n\nRESP: O2 SATS 100% ON 2L, PT REQUESTING O2 OFF - SATS REMAINS 99%, PT C/O OFF/ON SOB - UNRELATED TO SATS, LS CLEAR IN AM - BEGAN TO HAVE EXPIRATORY WHEEZES THROUGHOUT AFTER RECEIVING 1.5 L LR - LR SLOWED TO KVO - HOUSE STAFF CALLED - CXR DONE - NOT AWARE OF RESULTS - PT CONDITION IMPROVED ON OWN - NOT WEARING O2 AT PRESENT AND APPEARS COMFORTABLE\n\nGI: HAVING SM AMT BLOODY COLORED STOOL VIA RECTAL TUBE, TAKING SM AMTS CLEAR LIX, COUGHING AT TIMES AFTER SWALLOWING SIPS, W/O COMPLAINTS ABDOMINAL PAIN - ABDOMEN OBESE, SOFT, + BS; RECEIVING IVF BOLUSES OFF/ON - TOTAL 7 LITERS POSITIVE SINCE ICU ADMISSION; TOTAL BODY EDEMA - THIRD SPACED FLUID\n\nGU/RENAL: BUN/CR STABLE TODAY W/CR 2.9 FROM 3.0\nMINIMAL U/O TOTAL 200CC SINCE MN\n\nSOCIAL: SON IN TO VISIT THROUGHOUT DAY, AFTER PT/SON SPOKE W/SURGEONS TODAY PATIENT AND SON AGREED TO DECLINE SURGICAL OPTION, THEREFORE PT WILL CONTINUE TO BE MEDICALLY MANAGED - REMAINS DNR/DNI; ALSO OF NOTE - PATIENTS ENGAGEMENT RING W/CLEAR STONE AND PLAIN SILVER-COLORED WEDDING BAND REMOVED RN IN PRESENCE OF SON - GIVEN TO SON TO TAKE HOME.\n\nA: ISCHEMIC COLITIS W/RISING WBC'S BUT STABLE BP\n\nP: MONITOR BP, REPLACE LYTES AS NEEDED, GIVE FLUID AS TOLERATED AND FOLLOW O2 SATS, FOLLOW BUN/CR, EMOTIONAL SUPPORT FOR PT/FAMILY, CONTINUE SUPPORTIVE CARE, ? CALL OUT OF UNIT IN AM.\n\n" }, { "category": "Nursing/other", "chartdate": "2106-02-08 00:00:00.000", "description": "Report", "row_id": 1275816, "text": "ccu nsg progress note-micu border.\n88 yo female w ischemic cholitis, ?ischemic bowel, arf, metabolic acidosis, leukocytosis, & ?colon ca w liver/breast mets. pt is a dnr/dni & is refusing all aggressive interventions.\n\no:neuro=sl more lethargic then previous shift. easily arousable, but not as responsive. very needy-not wanting 2 be alone/constantly putting vcall light on-despite attempted limit setting. son-almost as needy as mother re:questions & addressing mothers needs.\n pulm=sat upper 90's on ra. c/o sob @ x's-does appear sob @ x's, but sats remain upper 90's. breath sounds=deminished throughout wo audible crackles despite being 8l positive.\n cv=hemody stable. access-peripheral iv's x3.\n gi=rectal tube in place. draining maroonish colored stool. guaic positive. tolerating ice chips & cl liquid sips.\n gu=foley. minimal ou.\n id=afebrile. abx- & flagyl as ordered.\n labs=unable 2 obtain. peripheral sticks x3 wo success. phlebotomy called.\n\na:multiple medical problems in elderly female.\n\np=?discussion re:comfort measures. contin present management. support pt/family as indicated. ?possible call-out.\n" }, { "category": "Nursing/other", "chartdate": "2106-02-06 00:00:00.000", "description": "Report", "row_id": 1275813, "text": "CCU NURSING BRIEF ADMISSION NOTE\nSEE CAREVUE ICU FHPA FOR ADMISSION HPI/PMHX\n\nBRIEFLY PT IS AN 88 YO WOMAN TRANSFERRED FROM 7 W/ISCHEMIC COLITIS, COLON MASS, INCREASING ACIDOSIS FOR CLOSER HEMODYNAMIC MONITORING.\n\nROS:\n\nCV: VS STABLE SINCE ADMISSION - HR 90-100'S SR-ST NOVEA, BP 112-130'S/SYST\n\nRESP: RR 20-30, LUNGS CLEAR, SATS 97-99% ON 2L NC, RARE EXERTIONAL WHEEZE NOTED\n\nGI: ABDOMEN OBESE, SOFT, DISTENDED, NPO EXCEPT ICE CHIPS, MEDS, LIQUID GUIAC POSITIVE STOOL X2 - RECTAL TUBE INSERTED W/SM AMT STOOL IN TUBE; PPN INFUSING AT 42CC/HR FROM FLOOR\n\nGU: FOLEY DRINING MINIMAL AMOUNTS URINE - IL NS BOLUS GIVEN - URINE LYTES SENT - CONTINUE TO INDICATE DEHYDRATION MD'S - 2ND IL BOLUS HUNG AT 1845\n\nID: AFEB, WBC 40'S AND CLIMBING RECEIVED FLAGYL, LEVO D/C'D PIPERACILLIN STARTED\n\nHEME: HCT 28 - T+S SENT TO BLOOD BANK\n\nSOCIAL: SON WHO IS HEALTH CARE PROXY IS HERE WITH [ATIENT, SPOKE W/MD'S HAS BEEN UPDATED REGARDING PT'S CONDITION AND PLAN OF CARE; PT MADE DNR/DNI IN CONSULTATION W/PT AND SON EARLIER TODAY, PT WOULD CONSENT TO A-LINE, CENTRAL LINE AND PRESSORS BUT NO INTUBATION OR CPR\n\nA: 88 YO WOMAN W/ISCHEMIC COLITIS W/INCREASING WBC'S, DECREASED BICARB\nON ANTIBX W/STABLE BP AT PRESENT\n\nP: CONTINUE FOLLOW BP/HR - FLUID BOLUS AND FOLLOW URINE LYTES, FOLLOW BUN/CR - ASSESS OUTPUT, CONT ANTIBX AND FOLLOW WBC'S, EMOTIONAL SUPPORT FOR PT/FAMILY.\n\n" }, { "category": "Nursing/other", "chartdate": "2106-02-07 00:00:00.000", "description": "Report", "row_id": 1275814, "text": "ccu nsg progress note-micu border.\no:very needy-does not like 2 be left alone. breath sounds=deminished throughout w/o audible crackles. appears short of breath & c/o that her breathing is heavy, but sats r upper 90's on 2l nc. rhythm-sr 2 st w/o ectopy. maps upper 70's. access-peripheral iv's x2. rectal tube- dark liquid stool. total 3.5l in w only 95ml out from to present. overall positive 5l. ivf presently @ kvo. afebrile w abx piperacillin & metronidazole. am labs sent @ 0430.\n\na:renal failure-hydrated w 3.5l wo improvement in uo.\n\np:support pt/family as indicated. pt needs limits set & maintained. continue present management.\n" }, { "category": "Radiology", "chartdate": "2106-02-03 00:00:00.000", "description": "CT 150CC NONIONIC CONTRAST", "row_id": 899983, "text": " 10:29 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV contrast. Please r/o ischemic colitis, diverticulo\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with recent URI, decreased PO, presenting with 5 hours\n grossly bloody diarrhea, benign abdominal exam, no pain.\n REASON FOR THIS EXAMINATION:\n PO and IV contrast. Please r/o ischemic colitis, diverticulosis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JVg WED 12:18 PM\n Large heterogeneous filling defect of ascending colon, suspicious for\n malignancy. Constrast seen distal to lesion with no small bowel dilitation.\n Hypodense liver lesions in right lobe of liver. Multiple sigmoid diverticuli.\n No evidence of diverticulitis. Scoliosis with degenerative changes through out\n spine and pelvis. Abnormal focal mixed heterogeneous lesions of fat, soft\n tissue, and bone density within mid abdomen--both intra and extraluminal.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Grossly bloody diarrhea. Rule out ischemic colitis,\n diverticulosis.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were\n performed with intravenous contrast. Delayed scans of the liver were\n performed. Multiplanar reformations were obtained.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: Within the right lobe of the liver,\n there are multiple hypo attenuatingareas, the largest of which occupy the\n majority of the posterior right lobe of the liver (segment V and segment VI).\n The portal veins are patent. The gallbladder, pancreas, spleen, adrenal\n glands and right kidney are unremarkable. There is a small simple renal cyst\n in the upper pole of the left kidney.\n\n Within the ascending colon, there is a large heterogeneous mass occupying\n extending from the cecum to the hepatic flexure. A 1-cm node is seen residing\n in the aortocaval region of the retroperitoneum (series 2, image 32). Contrast\n is seen within the small bowel and distal to the lesion within the large\n bowel. There is no small bowel dilatation. There is a small amount of\n stranding seen in the pericolic region adjacent to the large mass within the\n ascending colon. No free fluid or free air is seen within the abdomen.\n\n CT PELVIS: Just superior to the bladder, seen best in series 2, image 47,\n there are two bilateral heterogeneous lesions containing fat, soft tissue\n and calific density which do not show definite continuity with the uterus\n and/or ovary, but with appearnces suggestive of dermoids/teratomas. There is\n also a small intraluminal filling defect with possible tiny central fat\n density within the small bowel, 9 mm in diameter, of uncertain cause.\n there is wall thickening in the descending colon and there are multiple\n (Over)\n\n 10:29 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV contrast. Please r/o ischemic colitis, diverticulo\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n diverticula in the sigmoid colon with moderate amount of wall thickening which\n may be secondary to circular muscle hypertrophy, but appearances of\n 'thumbprinting\" are noted and cannot rule out segmental colitis/ischemia. The\n urinary bladder and uterus are unremarkable.\n\n LUNG WINDOWS: There are bilateral small scatterd illdefined nonspecific\n linear/patchy densities likely representing atelectases in the visualized\n portions of the lingula, RML and lower lobes and a tiny nospecific pleural\n based nodule in the left lower lobe. No pleural effusions.\n\n BONE WINDOWS: Hip screws are seen with in place in the proximal right femur.\n Lumbar scoliosis and degenerative changes in spine. Deformity and marked\n ossification indicative of prior fracture sites within the pubic rami\n bilaterally. Focal area of sclerosis in the left iliac bone and left sacral\n ala adjacent to left sacroliliac joint. A right buttock calcified lesion\n likely an injection granuloma is present.\n\n IMPRESSION:\n\n 1. Extensive heterogeneous soft tissue density involving the cecum and\n ascending colon with sharple marginated mass in region of hepatic flexure,\n most consistent with colonic malignacy with possible asssociated\n inflammatory/ischemic colitis. Multiple poorly defined low- density lesions\n within the right lobe of the liver, highly suspicious for liver metastases.\n Enlarged interaortocaval lymph node.\n\n 2. No evidence of large or small bowel obstruction.\n\n 3. Wall thickening in descending colon , inflammatory versus ischemic colitis.\n Sigmoid diverticulosis without evidence of diverticulitis, but either marked\n circular muscle hypertrophy or segmental colitis/ischemia of the sigmoid\n Correlate with endoscopy if indicated.\n\n 4. Mixed attenuation lesions bilaterally within the lower abdomen/pelvis\n likely representing bilateral dermoid/teratomas.\n\n 5. Small low attenuation filling defect within the small intestine of unclear\n etiology .\n\n 6. Sclerotic area sin left iliac bone and left sacral ala, as described.\n Lumbar scoliosis and old healed pubic rami fractures.\n\n (Over)\n\n 10:29 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV contrast. Please r/o ischemic colitis, diverticulo\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Echo", "chartdate": "2192-10-29 00:00:00.000", "description": "Report", "row_id": 83124, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 66\nWeight (lb): 430\nBSA (m2): 2.77 m2\nBP (mm Hg): 150/70\nHR (bpm): 80\nStatus: Outpatient\nDate/Time: at 14:53\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: No AS.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus.\n\nConclusions:\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. There is no aortic valve stenosis.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular systolic function.\n\n\n" }, { "category": "ECG", "chartdate": "2192-10-21 00:00:00.000", "description": "Report", "row_id": 227871, "text": "Sinus tachycardia. Otherwise, normal tracing. Since the previous tracing\nof no significant change.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2150-07-13 00:00:00.000", "description": "Intensivist Note", "row_id": 584263, "text": "CRITICAL CARE STAFF\n 23:15\n 60 y/o man with HCV cirrhosis (with varices, GIB, ascites) presents\n with\n Was called by hepatology clinic today\n slurred speech, falls.\n Referred to ED.\n In E/D\n I(-) CT without bleeding. BRPBR on exam, though no clear\n other clinical bleeding. Hct 30 (baseline 33 - 36)\n PPI, octreotide,\n hepatology consult. Was seen by hepatology in ED.\n PMH: cirrhosis with complications as above; alcohol use; tobacco use,\n mod PHTN on echo\n Meds: neurontin, lasix, lisinopril, nadolol, PPI, spironolactone,\n Tylenol\n HR 89 BP 115/79 RR 18 SaO2 98% r/a\n Oriented x 3\n No asterixis\n Spells WORLD and DLROW without error\n Some slowness in response\n ?left facial droop\n Speech is a bit slurred per those who know him\n Otherwise, CN intact\n Cor regular\n Lungs clear\n Abd not distended, no fluid wave, nontender\n Extr no edema\n CXR: prominent pulm vasculature\n Labs:\n Hct 30.8\n ?37 (calc Hct)\n WBC 13.6 (6% bands, 2% metas, 2% myelos, 1% promyelos)\n Plt 132\n Na 123 (slowly falling since about )\n Tbili 7.6 (highest to date), AST 228, ALT 132, alk phos 193, CK 346\n Assessment and Plan\n 60 y/o man with\n Some apparent confusion\n o Likely hepatic encephalopathy, though lack of asterixis is\n less consistent\n o Lactulose\n o Trigger is not clear. There is no clear infection, no\n ascites, and no evidence of UGIB.\n Possible LGIB\n o Hct is unclear; two values with conflicting results; 3^rd is\n pending\n o NGT placement attempted but unsuccessful in ED\n o On octreotide until hct returns. If stable, discuss with\n hepatology regarding discontinuing\n o If Hct stable and off octreotide consider transfer to floor\n Soft neurologic signs\n o Possible left facial droop, falls at home (but no vertigo\n here), and possible slurred speech\n o I doubt brainstem syndrome but will ask neurology to see\n tonight to confirm.\n Elevated bilirubin\n o Fractionate to exclude hemolysis as culprit\n ? myelophthisic smear\n o Discuss with usual providers\n o need further evaluation for infiltrative processes\n Other issues as per ICU team note. Discussed with pt.\n Critical care time: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2150-07-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 584314, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:10 PM\n NASAL SWAB - At 11:10 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 12:03 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 06:37 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: 36.1\nC (97\n HR: 79 (73 - 94) bpm\n BP: 109/53(66) {80/38(49) - 119/79(89)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 80 kg (admission): 80 kg\n Total In:\n 1,013 mL\n 38 mL\n PO:\n TF:\n IVF:\n 1,013 mL\n 38 mL\n Blood products:\n Total out:\n 750 mL\n 725 mL\n Urine:\n 750 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 263 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 10.9 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 95 mEq/L\n 125 mEq/L\n 32.1 %\n 14.1 K/uL\n [image002.jpg]\n 07:55 PM\n 11:02 PM\n WBC\n 14.1\n Hct\n 37\n 32.1\n Plt\n 137\n Cr\n 1.0\n TropT\n <0.01\n Glucose\n 78\n Other labs: CK / CKMB / Troponin-T:265/10/<0.01, Ca++:8.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n HEPATITIS OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2150-07-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 584317, "text": "Chief Complaint: confusion\n HPI:\n 60 yo M with Hep C cirrhosis, grade II esophageal varices, recent\n admission for UGIB NSAID gastritis, referred for admission throught\n the ED by hepatology clinic. Pt had called in to ask about recent\n medication changes and was noted by NP to have slurred speech and\n tangentail thought process. Also relayed hx of new imbalance leading to\n a fall during which he may have hit his head on . Per his brother\n (who lives in but speks to him by phone regularly), his\n speech has been off baseline since his discharge in . Pt's\n partner who lives in the area could not be contact to corroborate.\n Per last liver clinic note has been off ETOH since (corroborated\n with pt) and if stays off may be candidate for transplant list in \n .\n .\n In the ED, initial vs were: T=97.8 P=73 BP R O2 sat. Routine rectal\n exam revealed bright red blood in rectum and Hct was 30 which down from\n last measurement on but not really deviating from recent\n baseline. Pt did not tolerate NG tube placement. Seen by hepatology and\n started on IV PPI and octreotide drip. Hemodynamically stable\n throughout entire ED course. NCHCT done to r/o bleed given hx of head\n injury was unremarkable.\n .\n Neuro was consulted shortly after arrival to floor regarding concern\n for facial droop and slurrred speech. Per their initial eval, not\n concerning for acute ischemic infarct.\n ==============\n Medications:\n CLOBETASOL 0.05 % Ointment twice a day\n FLUOCINOLONE 0.025 % Cream\n FUROSEMIDE 40 mg daily\n GABAPENTIN 300 mg Capsule; Capsule(s) by mouth once daily takes prn\n for sleep or itch\n LISINOPRIL 10 mg Tablet daily\n NADOLOL 20 mg Tablet daily\n PANTOPRAZOLE 40 mg daily\n SPIRONOLACTONE 100 mg daily\n ACETAMINOPHEN 500 mg Tablet as needed for 2-3 times daily prn\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 12:03 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HCV Cirrhosis (tx with interferon x2 with no response)\n Portal Gastropathy\n Grade II Esophageal varices\n HTN\n Recent admission : UGIB non-steroidal induced gastritis\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives alone. He is drinking alcohol, usually one session per\n week. He has four to five drinks per session. He was told to completely\n abstain from alcohol, effective as of today. He smokes about 20\n cigarettes per day.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) 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, No(t) Dialysis\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: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 79 (73 - 94) bpm\n BP: 109/53(66) {80/38(49) - 119/79(89)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 80 kg (admission): 80 kg\n Total In:\n 1,013 mL\n 38 mL\n PO:\n TF:\n IVF:\n 1,013 mL\n 38 mL\n Blood products:\n Total out:\n 750 mL\n 725 mL\n Urine:\n 750 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 263 mL\n -687 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: jaundice\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, umbilical hernai\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 137 K/uL\n 10.9 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 27 mg/dL\n 22 mEq/L\n 95 mEq/L\n 5.0 mEq/L\n 125 mEq/L\n 32.1 %\n 14.1 K/uL\n [image002.jpg]\n \n 2:33 A7/6/ 07:55 PM\n \n 10:20 P7/6/ 11:02 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 14.1\n Hct\n 37\n 32.1\n Plt\n 137\n Cr\n 1.0\n TropT\n <0.01\n Glucose\n 78\n Other labs: CK / CKMB / Troponin-T:265/10/<0.01, Ca++:8.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Imaging: NCHCT (): No acute intracranial process.\n CXR (): No evidence of acute cardiopulmonary abnormalities.\n Hyperinflated lungs.\n Microbiology: ngtd\n ECG: NSR at 69, no STT changes concerning for ischemia, QT shorter than\n previous.\n Assessment and Plan\n HEPATITIS OTHER\n Assessment and Plan: 60 yo M w/ Hep C cirrhosis presenting with\n symptoms concerning for acute intracranial process but more likely \n progressive heaptiv encephlopathy. Incidentally found to have BRB in\n rectum in ED, hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. That said, maintianing two\n peripherals, t&s, cycling serial Hct q6h. Continuing octreotide given\n hx of varices, but will d/c in am after consultation with Hepatology.\n Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall. Starting lactulose\n .\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2150-07-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 584319, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:10 PM\n NASAL SWAB - At 11:10 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Clobetasol Propionate 0.05% Ointment FoLIC Acid\n Furosemide\n Gabapentin\n Lactulose\n Lisinopril\n Nadolol\n Octreotide Acetate\n Pantoprazole\n Spironolactone\n Thiamine\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 79 (73 - 94) bpm\n BP: 109/53(66) {80/38(49) - 119/79(89)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 80 kg (admission): 80 kg\n Total In:\n 1,013 mL\n 38 mL\n PO:\n TF:\n IVF:\n 1,013 mL\n 38 mL\n Blood products:\n Total out:\n 750 mL\n 725 mL\n Urine:\n 750 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 263 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 10.9 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 95 mEq/L\n 125 mEq/L\n 32.1 %\n 14.1 K/uL\n [image002.jpg]\n 07:55 PM\n 11:02 PM\n WBC\n 14.1\n Hct\n 37\n 32.1\n Plt\n 137\n Cr\n 1.0\n TropT\n <0.01\n Glucose\n 78\n Other labs: CK / CKMB / Troponin-T:265/10/<0.01, Ca++:8.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n HEPATITIS OTHER\n 60 yo M w/ Hep C cirrhosis presenting with symptoms concerning for\n acute intracranial process but more likely progressive hepatic\n encephalopathy. Incidentally found to have BRB in rectum in ED,\n hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. However to be cautious will\n maintian two peripherals, t&s, cycling serial Hct q6h. Continuing\n octreotide given hx of varices, but will d/c in am after consultation\n with Hepatology. Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall.\n .\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n ICU Care\n Nutrition: NPO\n Glycemic Control: none\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: IV PPI\n VAP: none\n Comments:\n Communication: With Patient Comments:\n Code status: Presumed Full\n Disposition: MICU -> may call out if stable Hcts\n" }, { "category": "Nursing", "chartdate": "2150-07-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 584409, "text": "60 yo M w/ Hep C cirrhosis presenting with symptoms concerning for\n acute intracranial process but more likely progressive hepatic\n encephalopathy. Incidentally found to have BRB in rectum in ED,\n hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. However to be cautious will\n maintian two peripherals, t&s, cycling serial Hct q6h. Continuing\n octreotide given hx of varices, but will d/c in am after consultation\n with Hepatology. Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall.\n .\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n Hepatitis other\n Assessment:\n Patient jaundiced A & O X 3, pupils pearla + hand grasps, lungs clear\n 100% on roomair, abd soft + bm soft brown no s/sx of frank blood, heart\n rate 60\ns sinus rhythm, systolic b/p 100-110 over60\n Action:\n Patient advanced to clears last HCT 33, continues on PPI gtt for GI.\n Response:\n Patient remains stable.\n Plan:\n Continue with current plan of care Notify team of any changes with\n patient.\n Patient on Octreotide Acetate gtt for ? upper GI bleed GI wants gtt on\n X24 hours started @ 2100 in ED.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n 79.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH, GI Bleed, Hepatitis\n CV-PMH: Hypertension\n Additional history: cirrhosis progressing to Liver Failure\n Grade II esophageal varices\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:62\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 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 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 809 mL\n 24h total out:\n 2,225 mL\n Pertinent Lab Results:\n Sodium:\n 126 mEq/L\n 05:59 AM\n Potassium:\n 5.0 mEq/L\n 05:59 AM\n Chloride:\n 94 mEq/L\n 05:59 AM\n CO2:\n 24 mEq/L\n 05:59 AM\n BUN:\n 27 mg/dL\n 05:59 AM\n Creatinine:\n 1.1 mg/dL\n 05:59 AM\n Glucose:\n 84 mg/dL\n 05:59 AM\n Hematocrit:\n 33.7 %\n 03:02 PM\n Finger Stick Glucose:\n 124\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu a\n Transferred to: 10 1016\n Date & time of Transfer: 07/01/0709 12:00 AM\n" }, { "category": "ECG", "chartdate": "2150-07-13 00:00:00.000", "description": "Report", "row_id": 193461, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno significant difference.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087114, "text": " 4:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with fall 3 days ago, now with AMS\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf MON 5:19 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old man with fall three days ago, and now with AMS. Evaluate\n for acute process.\n\n TECHNIQUE: CT head without contrast.\n\n COMPARISON: No images for comparison at the time of dictation.\n\n FINDINGS: No evidence of acute hemorrhage, edema or large acute territory\n infarction.\n\n The ventricles and sulci are normal in size and configuration. The visualized\n portions of paranasal sinuses and mastoid air cells appear normal.\n\n No definite fracture is seen.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1087116, "text": " 4:26 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with AMS, liver disease\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST.\n\n REASON FOR EXAM: liver disease.\n\n Cardiomediastinal contours are normal. The lungs are clear. There is no\n pleural effusion or pneumothorax. The lungs are mildly hyperinflated.\n\n IMPRESSION: No evidence of acute cardiopulmonary abnormalities.\n Hyperinflated lungs.\n\n" }, { "category": "Nursing", "chartdate": "2150-07-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 584374, "text": "60 yo M w/ Hep C cirrhosis presenting with symptoms concerning for\n acute intracranial process but more likely progressive hepatic\n encephalopathy. Incidentally found to have BRB in rectum in ED,\n hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. However to be cautious will\n maintian two peripherals, t&s, cycling serial Hct q6h. Continuing\n octreotide given hx of varices, but will d/c in am after consultation\n with Hepatology. Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall.\n .\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n Hepatitis other\n Assessment:\n Patient jaundiced A & O X 3, pupils pearla + hand grasps, lungs clear\n 100% on roomair, abd soft + bm soft brown no s/sx of frank blood, heart\n rate 60\ns sinus rhythm, systolic b/p 100-110 over60\n Action:\n Patient advanced to clears last HCT 33, continues on PPI gtt for GI.\n Response:\n Patient remains stable.\n Plan:\n Continue with current plan of care Notify team of any changes with\n patient.\n Patient on Octreotide Acetate gtt for ? upper GI bleed GI wants gtt on\n X24 hours started @ 2100 in ED.\n" }, { "category": "Nursing", "chartdate": "2150-07-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 584277, "text": "Hepatitis other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-07-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 584278, "text": "60 y/o man with HCV cirrhosis (with varices, GIB, ascites) presents\n with\n Was called by hepatology clinic today\n slurred speech, falls.\n Referred to ED.\n In E/D\n I(-) CT without bleeding. BRPBR on exam, though no clear\n other clinical bleeding. Hct 30 (baseline 33 - 36)\n PPI, octreotide,\n hepatology consult. Was seen by hepatology in ED.\n PMH: cirrhosis with complications as above; alcohol use; tobacco use,\n mod PHTN on echo\n Meds: neurontin, lasix, lisinopril, nadolol, PPI, spironolactone,\n Tylenol\n Hepatitis other\n Assessment:\n Pt with Hepatitis C cirrhosis, admitted with dizziness, slurred speech,\n suspicion for Lower GI bleed.\n Pt A+Ox3, slightly slurred speech, able to do serial calculations.\n Action:\n Started on Octreotide gtt.\n Response:\n No episodes of bleeding, Hct stable currently at 32.\n Plan:\n If remains stable ? c/o to floor versus d/c home, advance diet.\n" }, { "category": "Physician ", "chartdate": "2150-07-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 584347, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:10 PM\n NASAL SWAB - At 11:10 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Clobetasol Propionate 0.05% Ointment FoLIC Acid\n Furosemide\n Gabapentin\n Lactulose\n Lisinopril\n Nadolol\n Octreotide Acetate\n Pantoprazole\n Spironolactone\n Thiamine\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 79 (73 - 94) bpm\n BP: 109/53(66) {80/38(49) - 119/79(89)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 80 kg (admission): 80 kg\n Total In:\n 1,013 mL\n 38 mL\n PO:\n TF:\n IVF:\n 1,013 mL\n 38 mL\n Blood products:\n Total out:\n 750 mL\n 725 mL\n Urine:\n 750 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 263 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General: Alert, oriented, no acute distress, jaundiced\n HEENT: MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs/chest:: Clear to auscultation bilaterally, no wheezes, rales,\n ronchi, gynecomastia\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,\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 137 K/uL\n 10.9 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 95 mEq/L\n 125 mEq/L\n 32.1 %\n 14.1 K/uL\n [image002.jpg]\n 07:55 PM\n 11:02 PM\n WBC\n 14.1\n Hct\n 37\n 32.1\n Plt\n 137\n Cr\n 1.0\n TropT\n <0.01\n Glucose\n 78\n Other labs: CK / CKMB / Troponin-T:265/10/<0.01, Ca++:8.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n HEPATITIS OTHER\n 60 yo M w/ Hep C cirrhosis presenting with symptoms concerning for\n acute intracranial process but more likely progressive hepatic\n encephalopathy. Incidentally found to have BRB in rectum in ED,\n hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. However to be cautious will\n maintian two peripherals, t&s, cycling serial Hct q6h. Continuing\n octreotide given hx of varices, but will d/c in am after consultation\n with Hepatology. Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall.\n .\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n ICU Care\n Nutrition: NPO\n Glycemic Control: none\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: IV PPI\n VAP: none\n Comments:\n Communication: With Patient Comments:\n Code status: Full\n Disposition: MICU -> may call out if stable Hcts\n" }, { "category": "Nursing", "chartdate": "2150-07-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 584357, "text": "60 yo M w/ Hep C cirrhosis presenting with symptoms concerning for\n acute intracranial process but more likely progressive hepatic\n encephalopathy. Incidentally found to have BRB in rectum in ED,\n hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. However to be cautious will\n maintian two peripherals, t&s, cycling serial Hct q6h. Continuing\n octreotide given hx of varices, but will d/c in am after consultation\n with Hepatology. Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall.\n .\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n Hepatitis other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2150-07-14 00:00:00.000", "description": "Generic Note", "row_id": 584348, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Hct stable overnight.\n Comfortable this morning.\n 96.3 85 131/57\n Alert\n Chest\n clear\n CV\n 2/6 SEM\n Abd\n soft w/o tenderness\n WBC 12.8\n Hct 33\n AFP rising\n No evidence of further bleeding. Will complete another day of\n Octreotide and then d/c. Neuro will evaluate his gait today. Heme to\n see regarding abnormal diff. Rising AFP is omninous\n needs imaging.\n Time spent 30 min\n" }, { "category": "Physician ", "chartdate": "2150-07-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 584368, "text": "Chief Complaint: confusion\n HPI:\n 60 yo M with Hep C cirrhosis, grade II esophageal varices, recent\n admission for UGIB NSAID gastritis, referred for admission throught\n the ED by hepatology clinic. Pt had called in to ask about recent\n medication changes and was noted by NP to have slurred speech and\n tangentail thought process. Also relayed hx of new imbalance leading to\n a fall during which he may have hit his head on . Per his brother\n (who lives in but speks to him by phone regularly), his\n speech has been off baseline since his discharge in . Pt's\n partner who lives in the area could not be contact to corroborate.\n Per last liver clinic note has been off ETOH since (corroborated\n with pt) and if stays off may be candidate for transplant list in \n .\n .\n In the ED, initial vs were: T=97.8 P=73 BP R O2 sat. Routine rectal\n exam revealed bright red blood in rectum and Hct was 30 which down from\n last measurement on but not really deviating from recent\n baseline. Pt did not tolerate NG tube placement. Seen by hepatology and\n started on IV PPI and octreotide drip. Hemodynamically stable\n throughout entire ED course. NCHCT done to r/o bleed given hx of head\n injury was unremarkable.\n .\n Neuro was consulted shortly after arrival to floor regarding concern\n for facial droop and slurrred speech. Per their initial eval, not\n concerning for acute ischemic infarct.\n ==============\n Medications:\n CLOBETASOL 0.05 % Ointment twice a day\n FLUOCINOLONE 0.025 % Cream\n FUROSEMIDE 40 mg daily\n GABAPENTIN 300 mg Capsule; Capsule(s) by mouth once daily takes prn\n for sleep or itch\n LISINOPRIL 10 mg Tablet daily\n NADOLOL 20 mg Tablet daily\n PANTOPRAZOLE 40 mg daily\n SPIRONOLACTONE 100 mg daily\n ACETAMINOPHEN 500 mg Tablet as needed for 2-3 times daily prn\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 12:03 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HCV Cirrhosis (tx with interferon x2 with no response)\n Portal Gastropathy\n Grade II Esophageal varices\n HTN\n Recent admission : UGIB non-steroidal induced gastritis\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives alone. He is drinking alcohol, usually one session per\n week. He has four to five drinks per session. He was told to completely\n abstain from alcohol, effective as of today. He smokes about 20\n cigarettes per day.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) 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, No(t) Dialysis\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: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 79 (73 - 94) bpm\n BP: 109/53(66) {80/38(49) - 119/79(89)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 80 kg (admission): 80 kg\n Total In:\n 1,013 mL\n 38 mL\n PO:\n TF:\n IVF:\n 1,013 mL\n 38 mL\n Blood products:\n Total out:\n 750 mL\n 725 mL\n Urine:\n 750 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 263 mL\n -687 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: jaundice\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, umbilical hernai\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 137 K/uL\n 10.9 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 27 mg/dL\n 22 mEq/L\n 95 mEq/L\n 5.0 mEq/L\n 125 mEq/L\n 32.1 %\n 14.1 K/uL\n [image002.jpg]\n \n 2:33 A7/6/ 07:55 PM\n \n 10:20 P7/6/ 11:02 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 14.1\n Hct\n 37\n 32.1\n Plt\n 137\n Cr\n 1.0\n TropT\n <0.01\n Glucose\n 78\n Other labs: CK / CKMB / Troponin-T:265/10/<0.01, Ca++:8.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Imaging: NCHCT (): No acute intracranial process.\n CXR (): No evidence of acute cardiopulmonary abnormalities.\n Hyperinflated lungs.\n Microbiology: ngtd\n ECG: NSR at 69, no STT changes concerning for ischemia, QT shorter than\n previous.\n Assessment and Plan\n HEPATITIS OTHER\n Assessment and Plan: 60 yo M w/ Hep C cirrhosis presenting with\n symptoms concerning for acute intracranial process but more likely \n progressive heaptiv encephlopathy. Incidentally found to have BRB in\n rectum in ED, hemodynamically stable. Stable Hct.\n .\n # Concern for GIB: Given stable Hct & blood only found in rectum do not\n feel that this represents significant GIB. That said, maintianing two\n peripherals, t&s, cycling serial Hct q6h. Continuing octreotide given\n hx of varices, but will d/c in am after consultation with Hepatology.\n Also continuing IV PPI until AM.\n .\n # Altered mental status: Hx of unstable gait; Possible facial droop;\n Question over chronicity of slurred speech. This combination in\n conjunction with normal NCHCT is concerning for ischemic stroke. Neuro\n consult unimpressed by initial exam but will continue to follow. Will\n rpt NCHCT if exam changes as he is at risk for subdural given recent\n fall. Starting lactulose\n .\n #Rising AFP: Liver team made aware of this as it may significantly\n impact his prognosis\n # Worsening LFTs: greatest difference in BILI. Will fractionate and add\n hemolysis labs. Could be progression of cirrhosis as pt has failed\n interferon x 2.\n .\n # ETOH: Thiamine, folate, per pt and hepatology no longer drinking.\n Will monitor and start CIWA prn. ETOH on admission negative.\n .\n # Abnormal Diff: repeat diff as pt has no factors in his known medical\n hx to produce immature forms seen.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" } ]

[ { "category": "Radiology", "chartdate": "2101-11-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 773151, "text": " 2:20 PM\n CHEST (PA & LAT) Clip # \n Reason: 83 year old female with respiratory distress / please evalua\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with respiratory distress, cough\n REASON FOR THIS EXAMINATION:\n 83 year old female with respiratory distress / please evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n\n AP AND LATERAL CHEST: 14:28.\n\n INDICATION: Respiratory distress.\n\n COMPARISON: \n\n As compared to prior exam, there are persistent congestive changes but overall\n the appearance has improved. The right central venous catheter is identified\n with the tip at the junction of the SVC and right atrium. There is no\n pneumothorax. There are bilateral effusions and patchiness at the left lower\n lobe is consistent with pneumonia in the proper clinical setting. Upper lungs\n are clear of infiltrates.\n\n IMPRESSION: Improved fluid status. Findings consistent with left lower lobe\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772912, "text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pneumonia / CHF / ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with urosepsis, hypoxia, and then non Q wave MI\n\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia / CHF / ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, non-q-wave myocardial infarction. Please evaluate for\n pneumonia/CHF.\n\n COMPARISON: AP chest radiograph from .\n\n FINDINGS: Again demonstrated is a right sided subclavian central venous line\n with the tip at the junction of the superior vena cava and the right atrium.\n The ETT is in good position, with its tip several cm above the carina. The NG\n tube has the side port near the GE junction and should be advanced to avoid\n aspiration. There is a slight interval increase in the left ventricular size.\n There is also a diffuse increase in bilateral lung air space opacity which is\n most consistent with worsening congestive heart failure. An overlying\n pneumonia cannot be excluded.\n\n IMPRESSION: Worsening congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2101-11-09 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 773517, "text": " 5:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abdomen and pelvis to assess for retroperitoneal bleed\n Field of view: 39\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p MI, LAD stents, now with falling hematocrit\n REASON FOR THIS EXAMINATION:\n abdomen and pelvis to assess for retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83 year old woman status post MI and LAD stent with decreasing\n hematocrit. Assess for retroperitoneal bleed.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis without oral or IV contrast.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are small bilateral pleural\n effusions, left greater than right with atelectasis at the bases. The liver,\n gallbladder, pancreas, spleen and adrenal glands are unremarkable on this\n unenhanced study. The right kidney is unremarkable. There are several low\n attenuation rounded structures in the cortex of the left kidney, which may\n represent simple cysts, however evaluation is limited by absence of contrast.\n A tiny approximately 1 mm calcification is noted within the superior pole of\n the left kidney. This could be a vascular calcification or a nonobstructing\n stone. Extensive vascular calcifications are noted. Scattered mesenteric and\n retroperitoneal lymph nodes are noted that do not meet CT criteria for\n pathologic enlargement. There is no free air or ascites. There are multiple\n soft tissue densities scattered throughout the subcutaneous fat, consistent\n with injection sites.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is a large cystic mass measuring\n approximately 5 x 5 x 6 cm in the left adnexal region. Two smaller cystic\n structures are noted adjacent to this. By history the patient is status\n post hysterectomy and bilateral salpingooophorectomy. There is no free pelvic\n fluid. The rectum is unremarkable. There appears to be a tiny approximately 1\n mm bladder calculus in the region of the left ureterovesical junction. There\n is a small amount of air within the bladder, likely from prior\n instrumentation. There is a large amount of contrast within the sigmoid and\n descending colon. A large area of stranding is noted immediately adjacent to\n the right iliac and femoral vessels.\n\n Extensive degenerative changes are noted throughout the lumbar spine.\n\n IMPRESSION:\n 1. No evidence of a retroperitoneal bleed.\n 2. Slightly complex cystic mass in the left adnexa. This patient is\n presumably s/p hysterectomy and bilateral salpingo-oophorectomy. Given this\n history, this mass could be related to prior surgery. Appearances are not\n suggestive of a duplication cyst. If ovaries remain, ovarian neoplasm should\n be considered. Correlation with clinical history is recommended. Ultrasound\n may be helpful for further evaluation.\n (Over)\n\n 5:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abdomen and pelvis to assess for retroperitoneal bleed\n Field of view: 39\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Bilateral small pleural effusions, left greater than right with\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772845, "text": " 10:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Confirm endotracheal and NG tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with urosepsis, hypoxia, and then non Q wave MI\n REASON FOR THIS EXAMINATION:\n Confirm endotracheal and NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Urosepsis, hypoxia and a non-q-wave myocardial infarction. ETT and\n NG placed. Check position.\n\n FINDINGS: A normally exposed image and an overexposed image are provided. The\n ETT, the NG line and a right subclavian central line are well demonstrated and\n all appear to be in good position. The subclavian line tip is at the SVC right\n atrial junction. There is evidence of slight left ventricular enlargement of\n the heart. The lungs show some minor atelectatic_ changes in the left lower\n lobe behind the heart. Some illdefined infiltrate is present in the right mid\n zone. The pulmonary vessels are poorly defined. It is difficult to rule out\n slight LV decompensation. No definite effusions are demonstrated.\n\n IMPRESSION: 1) Satisfactory placement of lines. 2) Left lower lobe atelectatic\n changes noted. 3) Possible slight LV decompensation cannot be ruled out.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-11-02 00:00:00.000", "description": "Report", "row_id": 1598478, "text": "sepsis, mi\nccu npn- see fhpa also\nid- afebrile. wbc 25.4. on levoquin po and ceftriazone iv. urine c+s, u/a sent. - urine showed e.coli, blood c+s neg after 1 day.\ncv- hr high 80s-100s sr-st, no vea, bbb. bp 80s-100s in am, then 90s-117/ this pm, neo weaned off slowly, dopa down to 2mic/kg/min this pm. re'd 2 fluid boluses of 250cc each. heparin on 1100units/hr, ptt 57.8. integrilin on at 2mic/kg/min and d/c'd this pm. k-3.0, re'd total 80meq kcl iv. mg 1.8, re'd 2 amps iv x1. hct 37.2. ck .1, treponin >50, 2nd drawn here 190 and pnd. echo- ef 20%, etc. ekg with rbbb, l ant. hemiblock.\nresp- on vent 80% a/c, weaned to psv 10 with 5peep at 40%. abg done on 50% -92,33,7.48. sats 93-97. aline being inserted and a repeat abg to be drawn. l/s coarse/dim thruout. ett 6cm above carina per cxr per ho and advanced 2cm to 23. cxr results per radiology- lll atel, ?infiltrate r mid zone, ?sl. lv decompensation, etc.\ngu- u/o 30-60cc/hr. urine cloudy this pm. repeat urine sent and urine lytes sent. creat 1.5.\ngi- abd soft with b. sounds, denies abd pain. ogt inserted enroute, heard in good position and advanced 3cm per cxr per ho. ogt with small lt. green asp, guiac neg. iniially. later afternoon, aspirates thick brn, guaic pos. about 20-30cc ho aware. meds given, re'd prevacid (asa given pr). about 1 hr later, pt vomited mod. amt lt. brn liquid, pt denied nausea before or after vomiting. ogt to lis with small maroon thin liquid, ho aware. (integrilin d/c'd) ogt again clamped. prevacid changed to protonix iv. no bm.\nms- alert and appears oriented, cooperative. able to write and communicate well. on no sedation. ativan .5mg iv given x1 after vomited, rested with no further vomiting.\nsocial- married with 2 dtrs, 1 son, (NP)is proxy per pt/. has grandchildren, brother. many visitors today, limit for adequate rest periods. lives with husband and ?1 child with their spouse live in same house on different floor per pt (intubated). pt is independent at home, drives and is active (volunteers). uses no cane or walker.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-11-03 00:00:00.000", "description": "Report", "row_id": 1598479, "text": "CCU NPN 1900-0700\nO:\nPt. alert and responding approp. completely awake, coop.MAE. appearing uncomf. in eve, not sleeping. ativan .5mg x2 with good effect. last dose at 0100. dozing when left alone.\nCV; HR 80-90 ST. no VEA. BP via left rad. aline 85-100/40-50. dipping to 80's/ in eve. Rx with IVF boluses 250cc x4, last one at 0200. BP since stable >90/40's. MAP 60-65. Dopa was d/c'd at 2100.\nheparin remains at 1100u/hr.\nCK down to 190 in eve. pnd at 0500.\n\nRESP: stable at PSV 10/5/.40. sats 94-96%. ABG 7.44/35/74. suctioned q4hr for thick blood tinged secretions. RR 21-28. Tv 350-430.\n\nGU: u/o 30-40cc/hr (+) 800cc 12am and (+) 1.3l LOS.\nGI: OGT intact. dk. green bile , guiac (+). abd soft, ND.\nend: FS 140.\n\nA: dopa off. fluid boluses for low CVP/low grade hypotension with effect.\nP: wean to at 0600. follow ABG, sats, RR, etc. hold ativan for now pnd weaning protocol.\n" }, { "category": "Nursing/other", "chartdate": "2101-11-03 00:00:00.000", "description": "Report", "row_id": 1598480, "text": "NURSING PROGRESS NOTE 0700-1100\nRESP--WEANED AND EXTUBATED AT 0915. LOOKS GREAT. STRONG PRODUCTIVE COUGH. SAO2 ON 4L 92%. 50%FACE TENT ADDED FOR SAO2 96%. SPONT RESP24-29. DENIES SOB. OOB TO CHAIR WITH MIN ASSIST OF 1.\n\nCARDIAC--BP STABLE, HR SR/ST WITHOUT OBSERVED VEA. SEE FLOW SHEET FOR OBJECTIVE DATA.\n\nGI--STARTED ON CLEAR LIQ WITH DAT ORDERED. +FLATUS, NO STOOL.\n\nGU--FOLEY CATH PATENT DRAINING ~40 CC HR BROWN SLUDGY URINE.\n\nENDO--UNREMARKABLE AT PRESENT.\n\nSKIN--INTACT. BUTTOCKS WITHOUT BREAKDOWN.\n\nNEURO--AXO X3. INTACT.\n\nCOPING-FAMILY IN AT BEDSIDE. THEY ARE HAPPY THAT PT IS EXTUBATED AND OOB.\n\nA--STABLE POST EXTUBATION.\n\nP--CON'T TO MONITOR. ENCOURAGE PULM TOILET. OFFER SUPPORT TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2101-11-03 00:00:00.000", "description": "Report", "row_id": 1598481, "text": "1200 PT NOTED TACHYCARDIC AVERAGING HR 100 FOR MOST OF AM. 250 CC FLUID BOLLUS GIVEN ,INTIALLY HR DECREASING TO 90S BUT P BM 2PM PT C HR TO 130,SAT TO 90, BP TO 180 SYS. RESPONDED QUICKLY TO MSO4,LASIX, IV NITRO. REQUIRED O2 NP 4L BEFORE INCIDENT, NOW REQUIRES 100 REBREATHER FOR SAT 96. DIURESING C LASIX . K PENDING .EKG DONE NO CHANGES .PT DENIED CP .\n\nDENIES SOB .CRACKLES IN BASES.ON 100 REBREATHER C SAT 96\n\nTAKING FLUIDS SOFT SOLIDS ...NOT REQUIRING SSRI\n\nDIURESING ,URINE BR C SEDIMENT\n\nALERT,ORIENTED , NO CO . FAMILY C PT\n\nLOW EF ,HYPERTENSION PT IN DANGER OF FLASHING\n\nCONTINUE DIURESING\nCONTROL BP C NITRO, ACE BEING DISCUSSED\nWEAN O2 AS TOL\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-11-02 00:00:00.000", "description": "Report", "row_id": 1598477, "text": "RESP. NOTE\nAdmitted to unit intubted place on vent support. Able to wean in afternoon to PSV. Now on % with TV ~ 400cc RR teens to low twenties. Will cont support/ ? wean/extubated in am.\n" }, { "category": "Nursing/other", "chartdate": "2101-11-04 00:00:00.000", "description": "Report", "row_id": 1598482, "text": "CCU NPN 1900-0700\nS: \" I have to use the bedpan \"\nO: pt. requesting bedpan. liq. brown stool x3 small-med. guiac (+).\n\nHR 90's ST -> 80 SR when asleep. HR up to 100ST quickly with any exertion. no VEA. BP 104-120's/50's. MAP 70's TNG 1.4mcq/kg/min. heparin 1100u/hr. PTT 115: . to 950u/hr at 0430.\npt. denies SOB, CP through night.\n\ncaptopril started: 6.25 at 2100 and repeat 6.25mg at 2200, tol. well.\n\nRR 16-26. initially sats 92% on 4l and .50 face tent. FIO2 increased to 1.0 face tent and sats up to 94-97% through night. able to wean back down to 4l/.50 face tent. LS crackles bases. some upper airway congestion, unable to expectorate. did not tolerate cool neb mask and changed back to face tent.\n\nGU: u/o 50-100cc/hr. even for 12am and 900cc (+) LOS. no further lasix.\nneuro: alert and O. asking for sleep med. but then able to doze/sleep on own.\n\nA: ACE started. no further diuresis. sats improved.\nP: OOB again today. anticipate titrating ACE and ? adding Beta blocker. follow u/o. wean FIO2 as tol.\n" }, { "category": "Nursing/other", "chartdate": "2101-11-04 00:00:00.000", "description": "Report", "row_id": 1598483, "text": "CAPTOPRIL INCREASED, LOPRESSER STARTED. IV NITRO WEANED OFF. PT BECAME SOB ,HYPERTENSIVE .IV LASIX,MSO4,NITRO C GOOD EFFECT. NO CP. EKG NO CHANGES .\n\nCRACKLES INCREASED THIS PM, LASIX GIVEN .O2 REQUIREMENTS VARY 4L NP% REBREATHER TO KEEP SAT .> 93\n\nVOMITED MIN FOOD INTAKE\n\nDIURESING WELL TO LASIX\n\nALERT, ORIENTED .\n\nCONTINUE TO INCREASE CAPTOPRIL\nPO NITRATE\nCATH NEXT WEEK\n" }, { "category": "Nursing/other", "chartdate": "2101-11-05 00:00:00.000", "description": "Report", "row_id": 1598484, "text": "7p-7a Nursing Note:\nPlease see carevue for objective data:\n\nNeuro: At beginning of shift, Pt A/Ox3. Obeying and following all commands. MAE. Early this am, pt confused, pulling off 02 and trying to climb OOB. Wrist restraints applied for safety. Son at bedside.\n\nResp: At 0200, Pt dev resp distress, SPO2 88% on 4L NC. RR 30's. SOB at rest. LS clear, crackles at base. HR 110's. ABP 150-170's. NO C/O CP. MD made aware. Treated with 40mg IV lasix with good diuresis, total of 4mg IV MSO4 and pt place on 70% face tent- all with good effect.\n\nCV: Tele: NSR-ST with occ PVC's and BBB. ABP 110-140's/50-60's. Nitro gtt and wean to 1mcg/kg/min from 2.07 mcg. R SC TLC in place, CVP 3-5. PO captopril increased to 100mg po TID , Isosorbide 20mg po TID and Lopressor 12.5mg PO BID. NO c/o CP.\n\nGI/GU: Abd soft, +BS. Pt tol po meds/fluids. Foley in place and draining clear yellow urine, +1L diuresis from IV lasix given early this am. No BM. NO N/V.\n\nPlan:\nMonitor VS and wean off IV nitro\nMonitor neuro status/wrist restraints for safety\nMonitor for resp distress\nMonitor I&O's\nMonitor pending am labs\nCath lab early next week\nUpdate pt and family on plan of care\n" }, { "category": "Nursing/other", "chartdate": "2101-11-05 00:00:00.000", "description": "Report", "row_id": 1598485, "text": "CCU NPN 7a-7P\nNeuro: MS clearing this morning, now A&O x 3, answering questions appropriately, following commands. Confusion o/n r/t ambien? Pt reports confusion at home in the past after taking tylenol PM, ambien d/c.\n\nCV: Tele-SR-ST 80s-100s, RBBB, occ. PVC. ABP 100-130s via L radial Aline. CVP 4-7. NTG gtt weaned off, isordil increased to 40mg tid, lopressor increased to 25mg , capt cont at 100mg tid. K 3.2, repleted w/ 40mEq IV and 40mEq po. 3.7 this afternoon, repleted w/ an additional 40 IV. Mg 1.6, repleted w/ 2gm.\n\nPulm: Was on 70% face tent and 6L NC w/ sats in low 90s, crackles at bases, wheezes in upper fields. Given 40mg IV lasix, and neb treatment, sats now 93-96%. Was weaned to 4L NC but c/o dry air, changed to 40% face tent for humidification. Last ABG 7.50/38/83/31-r/t K repletion? Recheck later this eve. Down for PA/Lat chest x-ray, waiting for results.\n\nGI/GU: +BS, abd. soft, non-tender. Tol POs w/o difficulty. No BM today. Creat 1.2, good response to IV lasix. Goal 500-1000cc neg today. Foley patent, draining cl yellow urine.\n\nID: Afebrile, cont on ceftriaxone and levo.\n\nAccess: L radial Aline and R SC TLC.\n\nEndo: Covered w/ SSRI.\n\nSocial: Multiple members of family in throughout day, updated by RN.\n\nPlan: Goal 500-1000cc neg tonight. If does not flash again, d/c radial Aline and c/o to floor in AM. Cont to titrate cardiac meds as tol. Follow BS, cont IV Abx.\n" }, { "category": "Echo", "chartdate": "2101-11-02 00:00:00.000", "description": "Report", "row_id": 99515, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 87/44\nStatus: Inpatient\nDate/Time: at 14:53\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: There is severe regional left ventricular systolic\ndysfunction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).\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 is not well seen.\nPhysiologic (normal) pulmonic regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. There is severe regional left ventricular\nsystolic dysfunction with akinesis of the distal half of the anterior septum,\nthe apex, and distal anterior free wall. The inferior wall contracts best.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets are mildly thickened. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2101-11-07 00:00:00.000", "description": "Report", "row_id": 284144, "text": "Sinus rhythm\nIndeterminate frontal QRS axis\nright bundle branch block\nLow voltage\nLateral ST-T wave changes consistent with ischemia\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-11-08 00:00:00.000", "description": "Report", "row_id": 284145, "text": "Normal sinus rhythm\nIndeterminate QRS axis\nright bundle branch block\n Inferior/lateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-11-06 00:00:00.000", "description": "Report", "row_id": 284383, "text": "Sinus rhythm\nLeft axis deviation\nRight bundle branch block\nInferior infarct - age undetermined\nLateral ST-T changes consistent with ischemia\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-11-05 00:00:00.000", "description": "Report", "row_id": 284384, "text": "Sinus arrhythmia\nLeft axis deviation\nRight bundle branch block\nInferior infarct - age undetermined\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-11-03 00:00:00.000", "description": "Report", "row_id": 284385, "text": "Sinus tachycardia\nRight bundle branch block\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-11-04 00:00:00.000", "description": "Report", "row_id": 284386, "text": "Sinus tachycardia\nRight bundle branch block\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-11-03 00:00:00.000", "description": "Report", "row_id": 284387, "text": "Sinus tachycardia. Right bundle-branch block. Compared to tracing #1 no\ndiagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-11-02 00:00:00.000", "description": "Report", "row_id": 284388, "text": "Sinus tachycardia. Right bundle-branch block. Diffuse low voltage. Non-specific\nST-T wave abnormalities. Compared to the previous tracing of no\ndiagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-11-02 00:00:00.000", "description": "Report", "row_id": 284389, "text": "Sinus tachycardia\nMarked left axis deviation - consider left anterior fascicular block and/or\nprior inferior myocardial infarction\nRight bundle branch block\nLow QRS voltages\nNonspecific lateral T changes - clinical correlation is suggested for possible\nischemia\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Radiology", "chartdate": "2123-01-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1226164, "text": " 1:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P BLEED. EVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Subarachnoid hemorrhage. Please evaluate for interval change\n REASON FOR THIS EXAMINATION:\n\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg WED 2:09 AM\n subarachnoid hemorrhage in the left fronto-parietal-temporal lobes, unchanged\n from at 9:08pm. no new hemorrhage identified.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 65-year-old woman with subarachnoid hemorrhage. Evaluate\n for interval change.\n\n COMPARISON: CT head from Steward Hospital, at 9:08 PM on\n .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired through the head.\n Coronal and sagittal reformats were displayed for evaluation.\n\n CT HEAD WITHOUT INTRAVENOUS CONTRAST: Again seen is abundant hyperattenuating\n material in several left frontotemporal sulci and that sylvian fissure,\n representing acute subarachnoid blood. Allowing for differences in plane of\n scanning, this is similar in extent and distribution to the OSH study. There\n is no new hemorrhage. The blood does not extend into the ventricles or basal\n cisterns. The ventricles are normal in size and symmetric in configuration.\n Prominent right frontal extra-axial CSF space is likely due to asymmetric\n right frontal cortical atrophy. There is no mass effect or large vascular\n territorial infarct. There is no shift of the normally midline structures.\n -white matter differentiation is preserved. The visualized paranasal\n sinuses and mastoid air cells are clear. No osseous abnormality is\n identified.\n\n IMPRESSION: No interval change in the localized left frontotemporal\n subarachnoid hemorrhage, from the NECT at 9:08 p.m. on , roughly 4.5\n hours earlier.\n\n NOTE ADDED IN ATTENDING REVIEW: While this is a non-aneurysmal pattern of\n hemorrhage, it may be seen in a wide variety of non-traumatic etiologies,\n including Call- syndrome (RCVS), leptomeningeal amyloidosis and\n cervicocranial dissection, and should be closely correlated with clinical\n data.\n (Over)\n\n 1:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P BLEED. EVAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2123-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226219, "text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fever workup, unknown source\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with fever\n REASON FOR THIS EXAMINATION:\n fever workup, unknown source\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Fever.\n\n There are no prior studies available for comparison.\n\n There are low lung volumes. There is mild cardiomegaly, it is accentuated by\n the low lung volumes. There is mild vascular congestion. Nodular opacity in\n the right base is likely a calcified granuloma. There is another smaller\n rounded dense opacity projecting between fifth and sixth right posterior ribs,\n also likely a granuloma. There is no evidence of focal consolidation\n suggestive of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-28 00:00:00.000", "description": "RENAL U.S.", "row_id": 1226421, "text": " 4:50 PM\n RENAL U.S. Clip # \n Reason: H/O CYSTS, PLEASE EVALUATE NUMBER OF CYSTS AND SIZE, ACUTE RENAL FAILURE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with L SAH and acute renal failure\n REASON FOR THIS EXAMINATION:\n h/o cysts, please evaluate number of cysts and size\n ______________________________________________________________________________\n WET READ: 9:43 PM\n IMPRESSION:\n 1. No hydronephrosis. Echogenic renal cortex bilaterally consistent with\n chronic renal disease. Bilateral simple renal cysts as described above.\n 2. Incidentally noted, the gallbladder is distended and there is intrahepatic\n biliary dilatation with extra-hepatic dilation of the common bile duct. No\n gallstones are identified. An abdominal CT is recommended to assess the cause\n of the biliary dilatation.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old female with acute renal failure, SAH, and history of\n renal cysts.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The right kidney measures 10.6 cm and the left kidney measures 11.7\n cm. The kidneys are noted to be echogenic bilaterally consistent with chronic\n renal disease. No hydronephrosis is seen and no perinephric fluid collection\n is identified. Two simple cysts are seen in the right kidney, the largest of\n which is at the lower pole and measures 2.9 x 3.1 x 3.1 cm. Numerous cysts\n are seen in the left kidney. The largest is at the upper pole measuring 2.7 x\n 2.7 x 2.4 cm. The additional cysts in the left kidney range in size from\n 1.4-1.9 cm. All of the cysts seen in both of the kidneys appear to be simple\n cysts. No concerning solid renal mass is identified and no stones are seen.\n The urinary bladder is partially distended and is unremarkable.\n\n Incidentally noted within the right upper quadrant, the gallbladder is\n distended; however, no gallstones are identified. There is central\n intrahepatic biliary dilatation seen and the extrahepatic common bile duct is\n enlarged measuring up to 1.6 cm in size. The distal common bile duct is\n obscured from view by overlying bowel gas. The pancreas could not be\n identified.\n\n IMPRESSION:\n\n 1. No evidence or hydronephrosis. Echogenic renal cortex bilaterally\n suggesting medical renal disease. Several bilateral simple renal cysts as\n described above.\n\n 2. Incidentally noted, the gallbladder is distended and there is intrahepatic\n biliary dilatation with extra-hepatic dilation of the common bile duct. No\n gallstones are identified. An abdominal CT or MR is recommended to assess the\n (Over)\n\n 4:50 PM\n RENAL U.S. Clip # \n Reason: H/O CYSTS, PLEASE EVALUATE NUMBER OF CYSTS AND SIZE, ACUTE RENAL FAILURE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cause of the biliary dilatation; MRCP may be preferred as a non-contrast\n examination if renal failure is persistent or alternatively contrast-enhanced\n CT or MR could be considered following resolution of renal failure if\n applicable.\n\n These findings were conveyed to Dr. at 5:44 p.m. on , .\n\n" }, { "category": "Radiology", "chartdate": "2123-01-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1226634, "text": " 9:53 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New left arm 46cm D.L. power. ? PICC tip location\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with new left srm D.L. power PICC 46cm PICC. ? PICC tip\n location\n REASON FOR THIS EXAMINATION:\n New left arm 46cm D.L. power. ? PICC tip location\n ______________________________________________________________________________\n WET READ: LLTc SAT 10:08 AM\n New left PICC terminating at the mid to upper SVC. New Right basilar and\n possible left basilar consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: PICC line.\n\n FINDINGS: There is a new left PICC line terminating in the mid SVC. There is\n volume loss at both bases with more dense opacity in both lower lobes\n compatible with new infiltrates. Findings were discussed by Dr. with IV\n nurse Kigathi and at 10:05 a.m. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226683, "text": " 8:18 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Pulmonary edema?\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with SAH, now with some subjective dyspnea\n REASON FOR THIS EXAMINATION:\n Pulmonary edema?\n ______________________________________________________________________________\n WET READ: LLTc SAT 9:43 PM\n Continued poor lung volumes with bilateral hazy opacities, worse on the left,\n which may reflect infiltrates. Upper zone pulmonary vascular congestion has\n worsened, and there is superimposed pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Dyspnea, question pulmonary edema.\n\n REFERENCE EXAM: at 09:40.\n\n FINDINGS: The heart is mildly enlarged and is slightly more prominent than on\n the prior study. There is also pulmonary vascular redistribution and a patchy\n area of alveolar infiltrate in the right lower lobe. The overall findings are\n suggestive of mild CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-27 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1226177, "text": " 4:35 AM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST\n Reason:\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Subarachnoid hemorrhage. Elevated creatinine. Please evaluate for aneurysm\n REASON FOR THIS EXAMINATION:\n\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI BRAIN AND MRA BRAIN AND MRA NECK, \n\n HISTORY: Subarachnoid hemorrhage with elevated creatinine. Evaluate for\n possible aneurysm.\n\n Sagittal short TR, short TE spin-echo imaging was performed through the brain.\n Axial imaging was performed with diffusion, three-dimensional time-of-flight,\n , TR long TE fast spin echo, and gradient echo technique.\n Two-dimensional time-of-flight MRA was performed through the neck. Comparison\n to head CT studies of and .\n\n FINDINGS: Again demonstrated is signal intensity abnormality in the left\n hemispheric sulci, predominantly frontal and temporal, compatible with the\n diagnosis of subarachnoid hemorrhage. Within the limitations of comparing CT\n to MR, there is no evidence of increased hemorrhage since the prior study.\n The images of the brain otherwise appear normal. There is no evidence of\n infarction. There is no evidence of edema or masses.\n\n The MRA of the brain appears normal. Specifically, there is no evidence of\n aneurysm formation, arterial stenosis, or occlusion. The primary circle of\n branch points are well documented and appear normal. The left\n posterior inferior cerebellar artery origin is well demonstrated and appears\n normal. I do not detect a left anterior inferior cerebellar artery or a right\n posterior inferior cerebellar artery. However, there is an enlarged, and\n duplicated, right anterior inferior cerebellar artery. The vertebrobasilar\n junction and distal basilar artery appear normal. There is an area of\n possible narrowing in the distal right posterior cerebral artery, best seen on\n image 16 of series 104. However, this appears most likely to be an artifact.\n\n The distal cervical left internal carotid artery demonstrates irregularity\n with a slight outpouching, and just distal to this, a linear defect across the\n vessel. This suggests an atherosclerotic plaque, a dissection, or both.\n There is no evidence of either process extending intracranially, and this does\n not appear related to the subarachnoid hemorrhage.\n\n These findings were discussed with the neurosurgery service at 8:30 a.m. on\n in person by Dr. .\n\n CONCLUSION: No evidence of intracranial aneurysm.\n\n (Over)\n\n 4:35 AM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST\n Reason:\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Subarachnoid hemorrhage again demonstrated. Within the limits of comparing MR\n to CT, there does not appear to have been an increase in hemorrhage since the\n CT of or of .\n\n Apparent atherosclerotic plaque, dissection, or both in the distal cervical\n left internal carotid artery. This does not appear to be related to the\n subarachnoid hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-29 00:00:00.000", "description": "MRA BRAIN W/O CONTRAST", "row_id": 1226504, "text": " 10:10 AM\n MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: R/o aneurysm or other vascular anomaly; do time of flight\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with SAH, polycystic kidney disease\n REASON FOR THIS EXAMINATION:\n R/o aneurysm or other vascular anomaly; do time of flight\n CONTRAINDICATIONS for IV CONTRAST:\n BUN/CRE\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent subarachnoid hemorrhage. History of polycystic\n kidney disease and possible endocarditis. Evaluate for aneurysm or other\n vascular abnormality.\n\n COMPARISON: Head CT, . MRI/MRA brain, .\n\n TECHNIQUE: Routine non-enhanced MR examination with three-dimensional\n time-of-flight MR arteriography was performed.\n\n FINDINGS: The distal cervical internal carotid arteries have several loops\n and appear tortuous bilaterally. They appear similar to the previous MRA two\n days prior. Although there is no definite evidence for dissection or\n atherosclerotic plaque, these could be better evaluated with fat-saturated\n images. The patient could return to the radiology department at no charge for\n this subsequent imaging. As noted before, these abnormalities would not be\n related to the subarachnoid hemorrhage.\n\n Incidentally noted is a small infundibulum at the origin of the right\n ophthalmic artery, best seen on the source images. The remainder of the\n intracerebral vasculature appears normal. There is no evidence of aneurysm\n formation, arterial stenosis or occlusion. Specifically, the circle of \n and its branch points are normal.\n\n In retrospect, there are two small foci which are bright on DWI images and\n dark on ADC images in the left posterior parietal lobe and the left\n cerebellum. These are likely small acute infarcts, possibly from septic\n emboli.\n\n IMPRESSION:\n 1. Abnormality of the distal cervical internal carotid arteries is likely\n related to tortuosity. No definite dissection or plaque is visualized. For\n confirmation and better evaluation, fat saturated images should be performed.\n The patient can return to the radiology department at no charge for these\n images.\n 2. No intracranial aneurysms, dissections, or occlusions.\n 3. Two small infarctions in the left posterior parietal lobe and left\n cerebellum seen on the previous mr may be secondary to septic emboli.\n\n (Over)\n\n 10:10 AM\n MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST Clip # \n Reason: R/o aneurysm or other vascular anomaly; do time of flight\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Results were discussed with from neurosurgery at 1:45 p.m. on \n via telephone by Dr. .\n\n" }, { "category": "Echo", "chartdate": "2123-01-29 00:00:00.000", "description": "Report", "row_id": 94099, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 202\nBSA (m2): 2.01 m2\nBP (mm Hg): 106/45\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 15:33\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LAA. Good\n(>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. No\nspontaneous echo contrast in the RAA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\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: Small vegetation on mitral valve. Eccentric MR jet. Moderate to\nsevere (3+) MR. to the eccentric MR jet, its severity may be\nunderestimated (Coanda effect).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR.\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 monitored by a nurse e throughout the procedure. The patient was monitored by a nurse e throughout the procedure. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No\nglycopyrrolate was administered. No TEE related complications. The patient\nappears to be in sinus rhythm. Echocardiographic results were reviewed with\nthe houseofficer caring for the patient.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium or left\natrial appendage. No mass or thrombus is seen in the right atrium or right\natrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nOverall left ventricular systolic function is normal (LVEF>55%). The\nascending, transverse and descending thoracic aorta are normal in diameter and\nfree of atherosclerotic plaque to 35 cm from the incisors. The aortic valve\nleaflets (3) are mildly thickened. No aortic regurgitation is seen. There is\nsmall vegetation on the posterior mitral leaflet (P2). An eccentric,\nposteriorly directed jet of moderate to severe (3+) mitral regurgitation is\nseen. Due to the eccentric nature of the regurgitant jet, its severity may be\nsignificantly underestimated (Coanda effect). There is no pericardial\neffusion.\n\nIMPRESSION: Small posterior mitral valve vegetation. Moderate to severe mitral\nregurgitation.\n\n\n" }, { "category": "Echo", "chartdate": "2123-01-28 00:00:00.000", "description": "Report", "row_id": 94100, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 99\nBSA (m2): 1.48 m2\nBP (mm Hg): 130/46\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:13\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler. The IVC is dilated (>2.5cm)\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.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. No mitral\nvalve abscess. Mild mitral annular calcification. Moderate (2+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is mildly dilated. 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%). 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.\nModerate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.] There\nis the suggestion of a possible mitral valve vegetation on the ventricular\nside of the anterior leaflet in some views. There is mild pulmonary artery\nsystolic hypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size and wall thickness with\npreserved global and regional biventricular systolic function. Mild mitral\nvalve prolapse of the anterior mitral leaflet. Moderate mitral regurgitation.\nSuggestion of a possible vegetation on the anterior leaflet of the mitral\nvalve. Mild pulmonary artery systolic hypertension.\n\nIf clinical management would be impacted by the confirmation of a mitral valve\nvegetation, a transesophageal echocardiogram may be considered.\n\nDr. notified of the results by phone.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-02-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1227352, "text": " 4:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval change of subarachnoid bleed\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with SAH on , now with worse headache\n REASON FOR THIS EXAMINATION:\n Interval change of subarachnoid bleed\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n WET READ: 6:21 PM\n -Significant decrease in the amount of left frontoparietal subarachnoid\n hemorrhage.\n\n -No new intra or extra-axial hemorrhage.\n\n -No midline shift or evidence of herniation.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 65-year-old female with known subarachnoid hemorrhage, now with\n worsening headache. Evaluation for interval change.\n\n COMPARISON: Non-contrast head CT and MRI/MRA of the brain from .\n\n NON-CONTRAST HEAD CT: The previously described left frontoparietal\n subarachnoid hemorrhage has significantly decreased compared to prior head CT\n from . Minimal residual hemorrhage remains in the left\n frontal region (2:19, 16). No new intra- or extra-axial hemorrhage is\n identified. There is no mass, mass effect, or acute large territorial\n infarction. -white matter differentiation is grossly preserved. There is\n no shift of the usually midline structures. The suprasellar and basilar\n cisterns are widely patent. The ventricles and sulci are normal in size and\n configuration without evidence of obstructive hydrocephalus. There is no\n scalp hematoma or acute skull fracture. The visualized paranasal sinuses and\n mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. Interval decrease in the amount of left frontoparietal subarachnoid\n hemorrhage, now minimal.\n 2. No new intra- or extra-axial hemorrhage.\n 3. No mass effect or evidence of herniation.\n\n" }, { "category": "ECG", "chartdate": "2123-01-29 00:00:00.000", "description": "Report", "row_id": 245439, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2158-08-21 00:00:00.000", "description": "Report", "row_id": 63424, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 65\nWeight (lb): 163\nBSA (m2): 1.82 m2\nBP (mm Hg): 110/60\nHR (bpm): 122\nStatus: Inpatient\nDate/Time: at 16:59\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. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Severe global LV hypokinesis. Severely depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function\ndepressed.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\ncalcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA systolic\nhypertension.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\n1.The left atrium is moderately dilated. The left atrium is elongated.\n2.There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is top normal/borderline dilated. There is severe global left\nventricular hypokinesis with relative sparing of the basal inferolateral wall.\nOverall left ventricular systolic function is severely depressed.\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction appears depressed.\n4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen.\n5.The mitral valve leaflets are mildly thickened. There is severe mitral\nannular calcification. Moderate (2+) mitral regurgitation is seen.\n6. Moderate to severe [3+] tricuspid regurgitation is seen.\n7.There is moderate pulmonary artery systolic hypertension.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe present images are much better making it much easier to determine the LV\nfunction more accurately. Suspect previous LV function of , more than\npresent study but less than 55%.\n\n\n" }, { "category": "Echo", "chartdate": "2158-08-11 00:00:00.000", "description": "Report", "row_id": 63470, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Shortness of breath.\nHeight: (in) 65\nWeight (lb): 160\nBSA (m2): 1.80 m2\nBP (mm Hg): 142/65\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 16:30\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nPFO is present. Left-to-right shunt across the interatrial septum at rest.\nProminent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Normal LV cavity size. Moderately depressed LVEF.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section).\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient. Left pleural effusion.\nAnesthesia staff was present throughout the study (because patient has\ntracheostomy) and sedated the patient with propofol 40 mg IV.\n\nConclusions:\n1. A patent foramen ovale is present.\n2. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is moderately depressed. Posterior, lateral, and apical\nakinesis is present.\n3. The right ventricular cavity is mildly dilated. Right ventricular systolic\nfunction appears depressed.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. The mitral valve leaflets are structurally normal. Moderate (2+) mitral\nregurgitation is seen.\n6. Mobile fibrous strands are seen on the catheter in the SVC and right\natrium.\n7. No echocargiographic evidence of endocarditis seen.\n\n\n" }, { "category": "Echo", "chartdate": "2158-07-12 00:00:00.000", "description": "Report", "row_id": 63471, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 174\nBSA (m2): 1.87 m2\nBP (mm Hg): 148/64\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 11:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Torn mitral chordae.\n\nTRICUSPID VALVE: Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No vegetation/mass on pulmonic valve. No PS.\nThe end-diastolic PR velocity is increased c/w PA diastolic hypertension.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. 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 (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are\npresent. There is moderate pulmonary artery systolic hypertension. No\nvegetation/mass is seen on the pulmonic valve. The end-diastolic pulmonic\nregurgitation velocity is increased suggesting pulmonary artery diastolic\nhypertension.\n\nCompared with the prior study (images reviewed) of , no definite\nchange.\n\nIMPRESSION: No valvular vegetations seen. If clinically indicated, a TEE may\nbetter exclude a small valvular vegetation.\n\n\n" }, { "category": "Echo", "chartdate": "2158-06-23 00:00:00.000", "description": "Report", "row_id": 63472, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 213\nBSA (m2): 2.06 m2\nBP (mm Hg): 145/66\nHR (bpm): 80\nStatus: Outpatient\nDate/Time: at 15:17\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 prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded.\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). Minimally increased\ngradient c/w minimal AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severely\nthickened/deformed mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild (1+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate [2+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Left ventricular\nsystolic function appears grossly preserved. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded (n\nparticular, cannot exclude inferior hypokinesis). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. There is a minimally increased gradient consistent with minimal\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. The mitral valve leaflets are severely\nthickened/deformed. Mild (1+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is no\npericardial effusion.\n\nNo vegetation identified (cannot exclude).\n\nCompared with the prior study (images reviewed) of , there is no\ndefinite change (images technically suboptimal for comparison).\n\n\n" }, { "category": "Echo", "chartdate": "2158-07-28 00:00:00.000", "description": "Report", "row_id": 63498, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nBP (mm Hg): 154/72\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 14:05\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.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3).\n\nMITRAL VALVE: Severe mitral annular calcification. Mild (1+) MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: 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 normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. There is severe mitral\nannular calcification. Mild (1+) mitral regurgitation is seen. Significant\npulmonic regurgitation is seen. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of ,\nprobably no change.\n\nIMPRESSION:\nThere appears to be a small (0.7 x0.7 cm) mass attached to the highly\ncalcified mitral annulus. This could be a vegetation or a mobile piece of\ncalcification coming off the larger mitral annular calcification. No change\nfrom .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-26 00:00:00.000", "description": "Report", "row_id": 1608669, "text": "Condition update\nAssessment:\nPlease see carevue for details\n\n Neuro: pt a&ox3, but occationally hallucinating objects in room. Adequate light maintained to help with hallucinations. MAE, Follows all commands, PEERL. Denies pain.\n\n Resp: Remained on trach collar throughout night, tol well. Passy-muir valve intact, removed in short periods. Suctioned prn for small amounts of thick white sputum. LS coarse bilat throughout with occational expiratory wheezes heard in upper lobes. Inhalers prn with pos effect. Denies SOB. Trach care performed.\n\n CV: Remains in nsr, occational pvc's noted. Denies CP. VSS. +2 generalized edema noted.\n\n GI: Abd soft, NT, pos bs. Mod amount of loose brown stool from ileostomy. Vomited x1 at beginning of shift ~50cc of tubefeeds. Residual checked, 130cc. TF held for a couple of hours, r/s at 10cc/hr until new TF order arrives on floor. Even @ 10cc/hr, residuals 60-80cc. TF . Denies nausea at this point, no further vomiting.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n Endo: Insulin gtt remains off, bs remain labile, covering with s/s insulin.\n\n Plan: Continue pulm toileting, continue to closely monitor residuals, treat bs according to s/s, continue to monitor hemodynamics and mental status, provide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-03 00:00:00.000", "description": "Report", "row_id": 1608739, "text": "NPN 7p-7a\nNEURO: Pt is alert and oriented x3, using PMV to talk and eat. Pt would like to get up to chair today. No c/o pain. Pt following commands, MAE although weakly.\n\nCV: NSR 70s-80s, no ectopy. BP 130s-140s/40s-50s. Heparin gtt was running @ 750u/hr, but PTT's have not been successfully therapeutic (either too high or too low), therefore will only increase by 50u/hr.\n\nRESP: Pt tolerating trach collar well on 40% cool mist. sats 100%. LS clear, diminished @ bases. Suctioning thick yellow secretions, as pt can not always cough them up. RR 15-20.\n\nGI/GU: ABD soft, +BS. Illeostomy draining loose brown stool. Pt tolerating PO's well with aspiration precautions while eating. Pt also has post-pyloric NGT for meds. Foley draining minimal amounts of cloudy urine with alot of sediment.\n\n: Coccyx is pink, was broken but now healing with new . Duoderm changed. ABD is ecchymotic all over from old heparin injections.\n\nSOCIAL: pts husband called and by this RN.\n\nPLAN: Pt is c/o to floor, awaiting a bed. Possibly get pt OOB today, to lift her spirits a bit. F/U with PTT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-09-03 00:00:00.000", "description": "Report", "row_id": 1608740, "text": "Resp care note\n\nPt is on 40% cool neb, Q4 hr alb/atv by MDI and ambu. Pt req min sx, frequently able to cough airway clear\n" }, { "category": "Nursing/other", "chartdate": "2158-09-03 00:00:00.000", "description": "Report", "row_id": 1608741, "text": "Micu nursing note \n\nNeuro pt is awake and alert, oob-chir from well, pt feeding self\ncv pt stable on heperin drip 800u/hr, pt/ptt pending,\nresp pt on 40% trach collar, lungs decreased in bases, pt suctioned x1 for small amounts of white secrestions. on passymeir valve\nGi pt has bowel sounds x4, pt taking regular diet, pedi feeing tube dc'd today\nGU pt had foley which was dc'd at 9 am\nId pt afebrile,\na/p pt to be transferd to 10\n" }, { "category": "Nursing/other", "chartdate": "2158-07-25 00:00:00.000", "description": "Report", "row_id": 1608667, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: CONFUSED AND RESTLESS THIS AM. ATIVAN GIVEN PO X1. PT SLEEPING IN NAPS SINCE. MORE COOPERATIVE.\nCV: T MAX 100. HR 65-80 NSR WITH PVC'S. SBP 130-170.\nRESP: REMAINS ON TRACH COLLAR AT 50%. BS COARSE. SX FOR SM AMTS THICK WHITE SECRETIONS. PT COUGHING UP SECRETIONS ALSO BY HERSELF. PASSEY MUIR VALVE PLACED AT 1600 = MINIMAL VERBAL EXCHANGE FROM PT= \"I JUST WOKE UP\"\nGI: ABD SOFT. ILEOSTOMY PATENT WITH LOOSE BROWN STOOL. BAG CHANGED BY OSTOMY NURSE, TOL TF ALL SHIFT (ONLY OFF FOR RADIOLOGY TRIP)\nGU: LASIX IV X1 WITH FAIR RESPONSE. CLEAR YELLOW URINE VIA FOLEY\nENDO: INSULIN GTT REMAINS OFF. , FOLLOW SLIDING SCALE AND LANTIS DOSE QPM. SEE CAREVUE FOR BS\nIV: TO RADIOLOGY FOR PLACEMENT OF DOUBLE LUMEN PICC IN RIGHT ARM\nA/P : TO MONITOR HEMODYAMICS AND RESP PARAMETERS. CHECK BS Q4HRS AND ADMINISTER SLIDING SCALE AS INDICATED, ? D/C DIALYSIS CATHETER NOW THAT PICC IS IN PLACE, ? TRANSFER TO FLOOR IN AM\n" }, { "category": "Nursing/other", "chartdate": "2158-07-26 00:00:00.000", "description": "Report", "row_id": 1608668, "text": "Respiratory Care Note:\n patient remains on a 50% cool mist trach collar this shift. BS are coarse. MDI's administered as ordered. Patient able to raise secretions, no sx needed. Tmax this shift was 99.4. SPO2 remained 98-100%. PMV currently on and cuff is deflated. RR remains 21-24.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-21 00:00:00.000", "description": "Report", "row_id": 1608650, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT LETHARGIC TODAY, TO VOICE, FOLLOWING COMMANDS AND ABLE TO NOD. MOVING ALL EXT. NO COMPLAINTS OF PAIN.\nCV- BP STABLE IN 120-140 RANGE, HR 70'S, NSR. OCCASIONAL PVCS AND VENT TRIGEMINY WITNESSED BY TEAM THIS AM. LYTES TO BE FOLLOWED AND REPLETED IF NECESSARY. HCT DROPPED SLIGHTLY AND WILL MONITOR.\nRESP- LUNGS CLEAR, RAISING SMALL AMOUNTS OF TANNISH THICK SPUTUM, WILL SEND FOR CULTURE. REMAINS ON VENT UNTIL LETHARGY IMPROVES, PRESSURE SUPPORT WEANED TO 10 AND PT TOLERATING WELL.\nGI/GU- ABD SOFT, BRUISING ACROSS ABD. NOTED BY TEAM, BE DUE TO HEPARIN INJ FROM THE PAST. SC HEPARIN REORDERED AND DRIP OFF. ILEOSTOMY DRAINING LARGE AMOUNTS OF LIQUID BROWN STOOL, COLACE SHOULD BE HELD. MINIMAL, 15-35, CLEAR YELLOW URINE.\nID- 101.9 RECTAL, TEAM AWARE THAT PT IS FEBRILE. WILL TREAT WITH TYLENOL AND BLOOD CULTURES SENT AND PENDING THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-24 00:00:00.000", "description": "Report", "row_id": 1608661, "text": "focus hemodynmics\n\ndata: neuro: lethargic tonite although engages in conversation. at times becomes disoriented as to her where about. needs to be reoriented. moves all extreimities on the bed. assists in turning in the bed.\n\nresp: suctioned for thick white sputum. ips 12. trach patent and care done x 3. rsbi 32.\n\ncardiac: in nsr with occ pvc. on iv hydralazine, clonidine and lopressor.\n\ngu: foley patent and draining yellow urine.\n\ngI abd soft. having residuals > 120cc. fdgs held. restarted and tol ok. ileostomy patent and draining brown liquid stool.\n\naction: suctioned prn. labs as ordered. tube fdgs restarted. reglan 5mg iv given. insulin gtt started due to blood sugars> 200. ns at 20cc/hr. tylenol 650mg via ngt given temp down to 100.4.\n\nrespnse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-24 00:00:00.000", "description": "Report", "row_id": 1608662, "text": "RESP CARE: Pt remains trached with 6.0 Portex trach tube on PS ventilation of 12 all noc. Vts 500-600/RR 15-30. Lungs coarse rhonchi bilat. Sxd white sputum. MDIs as ordered with good effect noted. RSBI on 0 PEEP/5 PS was 32. Wean as tol to trach collar.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-01 00:00:00.000", "description": "Report", "row_id": 1608731, "text": "NPN 7p-7a\nNEURO: Pt alert and oriented x3, and speaking with valve on for begining of shift. Pt then slept most of night. No c/o pain. MAE ad lib. Pt is very excited to be doing better and looking forward to starting rehab.\n\nRESP: Pt has been off of vent for 48hrs now and tolerating well. Pt is on 40% trach collar with sats>98%. Suctioning thick yellow secretions, as pt occas has hard time coughing them up. LS clear, diminished @ bases. RR 15-22.\n\nCV: NSR, with occas going in/out of afib. Pt is now on amiodarone and on heparin gtt @ 650u/hr. HR 60s-90s, with occas PVCs. BP 120s-140s. Pt is on Lopressor, hydralizine, and isordil.\n\nGI/GU: ABD is soft, +BS. Illeostomy draining brown liquid stool. TFs @ goal 40cc/hr. Pt has been cleared by speach/swallow to take POs and did eat full dinner last night. TFs will continue until pt is taking in enough POs and is surely off the vent. U/O has improved, 15-30cc/hr of yellow cloudy urine.\n\nID: Pt has been afebrile, on ceftaz for PNA and vanco renally dosed per level.\n\nSocial: Pts husband called and updated by this RN.\n\nPLAN: Pt may have HD today depending on fluid balance. ? possible transfer to rehab or out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-01 00:00:00.000", "description": "Report", "row_id": 1608732, "text": "Respiratory care:\nPatient followed for trach checks and bronchodilator therapy. Breathsounds are decreased. Albuterol/atrovent mdi given with spacer via trach. Suctioned for scant amounts of thick white secretions this am. Continues on 40% trach collar. Please see respiratory section of carevue for further data.\nPlan: Continue to monitor respiratory status. Remains off vent greater then 48/hrs.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-01 00:00:00.000", "description": "Report", "row_id": 1608733, "text": "Patient on 40% T-mask all day. Suctioned periodically for small amount of thick yellow to white scant secretion. Placed on Passy - muir valve for many hours while eating and husband presence.Dialysis done this PM. Passy-muir valve removed @ 16:30 cuff re-inflated,trach care done. Patient has # 6 Portex does not adequately with inner canula inserted had to remove to maintain good pattent airway. # 5 inner cannula hard to find.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-24 00:00:00.000", "description": "Report", "row_id": 1608616, "text": "NPN 0700-1900:\nNeuro: Pt is lethargic, fatigued, , responsive to verbal stimuli, easily , MAEs, denies any pain or discomfort, pt has some blurred vision, but opens eyes when asked to.\n\nResp: Breathing regularly on O2 NC 3 L/min, breathing looks somewhat better than yesterday and pt never c/o SOB, LS crackles with mild exp wheezes occasionally, RR 14-20, SPO2 95-98%, with a tracheostomy in place (opening), trach care done, suctioning done for moderate purulent thick secretions, CXR revealed pleural effusion.\n\nCV: AFib HR 8-=83, BP 138-157/57-83, with a LSC central line, on insulin drip @ 1 unit/hr, FS taken hourly ranged 57-171, peripheral pulses weakly palpable on Rt leg, (Rt BKA), on antibiotics Vancomycin and Cefepime, and ob Fluconazole IV.\n\nGI/GU: On regular diet, tolerated the soft diet and liquids well, eats slowly, takes pills slowly and one at a time, abdomen obese, BS present, with ileostomy drained soft brownish stool, with Foley cath drained 7-15 cc/hr U/O. US and CT scan of abd and pelvis done yesterday revealed air in the bladder with hydronephrosis.\n\nInteg: Pt has many hematomas all over the abdomen probably from injections, with edema over extremities, T max 97, ptis on contact precaution to MRSA in blood.\n\nSocial: Husband called twice and updated on pt'd health condition, will be in to visit this evening, pt is full code.\n\nPlan: Try to insert a new central line with the help of ultrasound and D/C the present one and send tip for cx, if nunsuccessful change present line under a guidewire, insert an A-line, D/C Fluconazole and continue antibiotics, continue antihypertensive drugs ( (Clonidine, Isosorbide, Metoprolol, and hydralazine), continue insulin drip even though pt is hypoglycemic (give Dextrose PRN), monitor breathing pattern and if distresses ? intubation, give Lasix and if no response considr dialysis within the next few days.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-24 00:00:00.000", "description": "Report", "row_id": 1608617, "text": "Respiratory Care:\nPt wanted to return to NC @ 3 l/m early this AM and has been fine on the cannula since. No bronchodialators have been given.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-04 00:00:00.000", "description": "Report", "row_id": 1608680, "text": "Nsg Progress Note 0700-1900\n\nCV - Pt hemodynamically stable. Afebrile. Hct stable but low at 23. require blood transfusion later.\n\nResp - Pt with valve in all day and no O2 - No c/o SOB or difficulty breathing. O2 sats 98-99%.\n\nGI - Tolerating ice chips very well. C/O very dry mouth. Also tolerating TF's very well. Abd soft with positive BS. Ileostomy draining mod amt green liquid stool.\n\nGU - no foley - no urine output. Pt to dialysis at 3pm.\n\nEndocrine - BS low to 46 - given amp D50 with increase to 116.\n\n - Coccyx with duoderm intact otherwise intact. Dialysis line and PICC line both intact with sites WNL.\n\nNeuro - Pt alert and oriented x3. MAE and very appropriate and helpful. She is still slightly sleepy but easily arousible.\n\nSocial - Husband called in the morning and visited in the afternoon. Very supportive and well informed of pt's .\n\nPt to return to MICU after dialysis but is called out and can be transferred as soon as a room is available.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-21 00:00:00.000", "description": "Report", "row_id": 1608651, "text": "Respiratory Therapy\n\nPt remains trached/mechanically ventilated. Weaned IPS to +10, pt tolerating well, maintaining Ve ~10L. BLBS coarse, suctioned for small amounts of thick tan sputum, sample sent to lab for culture. SpO2 90s. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support; continue to wean toward trach collar trials as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2158-07-22 00:00:00.000", "description": "Report", "row_id": 1608652, "text": ",\nPt. remains on IPS overnoc. IPS increased to 12 this shift due to prolonged tachypnea. RR now 28. Suctioned frequently for tan sputum. RSBI 57 this am. Plan to wean IPS as tol.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-22 00:00:00.000", "description": "Report", "row_id": 1608653, "text": "focus hemodymics\ndata: neuro: lethargic tonite. opens eyes when name being called. mouthing words. moves all extremities on the bed and assists in turning in the bed. hands grasps equal.\n\nresp: trach patent and trach care done x2. suctioned for mod amt of thick white sputum with occ plugs. on cpap with 10 ips. resp rate in the 30's. dr notified. ips increased to 12. rsbi good this am.\n\ncardiac: in nsr with occ pvc. k 4.7-5.1. hydralazine and clonadine given as ordered.\n\ngu: foley patent and draining yellow urine.\n\ngI abd soft ilieostomy patent and stoma red and protruding. loose brown stool. tube fdgs infusing and tol well.\n\naction: suctioned prn. on iv pipercilin. tol tube fdgs. trach care done x3. hct 22.7 tonite 1units prbc given over 3hrs. tol well.\n\nresponse: monitor closely\n" }, { "category": "Nursing/other", "chartdate": "2158-08-30 00:00:00.000", "description": "Report", "row_id": 1608725, "text": "NPN 7p-7a\nEVENTS: Pt tolerating CVVHD well, with goal of ultrafiltrating 100cc/hr being met. Pt was negative over 2L @ MN and will most likely be changed over to HD when this clots off. At around MN, pt became subjectively SOB on 40% trach collar. Pt had been tolerating all day very well, but c/o getting tired. RR was briefly in 30s, VBG wnl, and seemed more anxiety provoked than actually in any resp distress. Dr was notified and had pt placed back on CPAP+PS 40%/ for the rest of night.\n\nNEURO: Pt was alert most of shift, sleeping on/off. Pt is mouthing words to meet needs, and appears oriented-following all commands. No c/o pain. Pt does move upper extremities, weakly and does need help with turning/repositioning.\n\nCV: NSR/ST 80s-105, with occas PVCs. BP 104-150s/30s-80s, on Lopressor for rate control. Heparin gtt @ 800u/hr with sliding scale, KCL, and Ca Gluconate also infusing with sliding scale for CVVHD. Checking labs Q6H (10/1600). Pt has been afebrile.\n\nRESP: Currently on CPAP+PS, as stated above. Sats 98-100%, no further c/o of SOB. Suctioning thick yellow secretions, Q2-3H. LS coarse upper but clear with suctioning, diminished @ bases. RR 16-25.\n\nGI/GU: ABD is soft, +BS. Illeostomy draining liquid brown stool. TFs @ goal 40cc/hr via Pedi tube. U/O marginal, foley draining cloudy yellow urine with sediment. 10-25cc/hr.\n\nENDO: Pt is on Q4H FS, BS 142-233.\n\nSOCIAL: Pts husband called and updated by this RN.\n\nPLAN: Continue CVVHD with 100cc/hr fluid removal until clots, and then call MICU resident to re-assess. Pt will be changed over to HD most likely. Goal to put pt back on trach collar today, and continue as long as possible. Pt needs much reassuring to continue off of vent due to anxiety.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-22 00:00:00.000", "description": "Report", "row_id": 1608654, "text": "SICU NPN\nS-Trached.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Remains lethargic. Opens eyes to voice and follows commands appropriately. Asking appropriate question. Asked if tired and pt nodding \"yes.\" MAEs to command and spontaneously. HR 60-80s. NS with frequent PVCs and couplet. Lytes pending. SBPs 120-140s. Tolerating Isordil, Hydralazine, Clonidine, and Lopressor well. Breaths sounds clear. Dim at right base. Remaining on PS for day. Plan is to continue to rest today and attempt to trach collar tommorow. VBG, 7.33/40/ with bicarbonate of 22. Dr. aware and continuing to monitor. RR 30s with Spont TV in the 300s. Appears comfortable and denies SOB or difficutlty breathing. Oliguric. Urine yellow and light in color with some sediment and cloudiness. Urine cx pending from this morning. Abd soft with bowel sounds. Ileostomy intact with brown loose to liquid stool. TFs residuals 125ccs. TFs held for 2hrs and restarted back at 10cc/hr and advancing slowly as tolerated. If continues not to tolerate will start Reglan. GR 35cc/hr. Low grade temps. Pan cultured at change of shift for temp of 102. Continues Zosyn and Vanco. Vanco trough at 7a prior to AM dose today. FS at 8am, 445, started on Insulin gtt. Insulin gtt off at noon. Treating with RISS starting at 1400 for FS of 143. Following Q2H until stable. Husband and friend into visit for couple hours. Husband will call later tonight.\n\nA/P: Failure to wean, question source of sepsis.\nContinue to rest on IPS\nContinue to follow glucoses closely\nVanco level prior to AM dose\nContinue to monitor\n" }, { "category": "Nursing/other", "chartdate": "2158-07-22 00:00:00.000", "description": "Report", "row_id": 1608655, "text": "Respiratory Therapy\n\nPt remains trached w/ #6.0 on PSV. No vent changes made this shift. Suctioned for small amounts of thick tan sputum. MDIs given as ordered. SpO2 90s. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; continue to wean towards trach collar as tolerated...\n" }, { "category": "Nursing/other", "chartdate": "2158-07-23 00:00:00.000", "description": "Report", "row_id": 1608656, "text": "RESP CARE: Pt remains trached with 6.0 Portex trach tube/cuff pressure 23cmH20. Pt on vent on PS 12/PEEP 5/.40. Vts 540-650/RR 10-15. Pt rresting comfortably. Lungs Few wheezes R>L, decreased congestion noted in LLL. Sxd thick pale yellow sputum. RSBI this am on 0 PEEP/5 PS was 34!. Plan is to attempt trach collar trial again today.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-23 00:00:00.000", "description": "Report", "row_id": 1608657, "text": "focus hemodynmics\ndata: neuro: more awake tonite. smiling. engaging in conversation. slept in short naps. at times becomes nervous especially when being suctioned.\n\nresp suctioned for thick white sputum. on cpap with 12 ips. attempted to place on cpap 5/5 but became very anxious. vent alarm sounding. pt back on cpap . wbc 14.4. trach care done x3.\n\ncardiac: in nsr with pvc's. hct 27.4, ion ca 1.56. mag 1.8\n\ngu: foley patent and draining yellow urine. creat 2.7 and bun 150.\n\ngI abd soft and iliostomy bag intact and draining brown liquid stool. lg amt flatus in bag. tube fdgs tol well with minimal residual.\n\naction: suctioned prn. labs as ordered. insulin gtt started for blood sugar > 300. tube fdgs increased to 30cc/hr. pipercillin iv q6hrs.. ostomy draining brown liquid stool.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-01 00:00:00.000", "description": "Report", "row_id": 1608734, "text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-vs have been stable, receiving po cardiac meds (some held during dialysis) lopressor dose increased.bp stable during HD\n\nRESP-has remained on trach collar 40% with good o2 sats.no c/o SOB. PMV placed by RT and pt speaking to husband, staff.has been sx freq for thick white/yellow sputum.has a good cough.receiving inhalers as per RT.\n\nGI-abd is soft with positive bowel sounds.passing thick lquid stool via colostomy.tube feeds d/cd as pt can eat a full meal, has been eating well.\n\nID-afebrile.on ceftaz for pna and renally dosed with vanco prn.\n\nENDO-has had increased blood sugars while both eating and receiving tube feeds- insulin sliding scale was tightened up.\n\nF/E-was dialysed x 2 hours today.took off 1.8 kgs.also has been voiding ~25-30ccs/hr via foley. has some mild peripheral edema.please see labs as listed in carevue\n\n\nIV ACCESS-has a L antecub PICC, looks good, dressing changed.\n\nSOCIAL-husband in to visit and has phoned many times.updated by this RN. he met with patient relations representative today.\n\na-stable, uneventful day. tolerated HD\n\nP-will watch i's and o's, labs. RISS. continue with good pulm toilet.husband needs much support.may be ready for the floor soon.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-21 00:00:00.000", "description": "Report", "row_id": 1608681, "text": "MICU 7 0700-1900 NPN\n\n55 YO woman with a hx of DM, kidney failure, heart disease, CABG x2, and fungemia. Patient has been in the hospital since . Transferred to MICU from CC7 due to hypotension and desat to 70-80's. Had 1200cc bolus on the floor and one more 500cc bolus in the MICU with some effect. Patient desat to 79% after arriving to the MICU, gave albuterol neb . with good effect. Full Code.\n\nNeuro: Pt. A/O x3 for most of shift. Is confused at times, but re-orients easily. Pt. denies any pain. UE/LE's are very tremulous, MD aware.\n\nCV: Patient has been ST most of shift with rare PVC's. SBP 79-93. MAP > than 60 for most of shift. PT denies chest pain. Right pedal pulse is easily palpable. NBP taken on Right leg. Patient is tired of cuff being on arms.\n\nResp: Patient remains trach at 50%. Sat's have been >95% for most of shift. Desat x2 this shift. Gave albuterol neb with good effect. Rhonchi in upper lobes and diminished in lower lobes. Sx for minimal thick white secretions.\n\nGI/GU: Ileostomy bag intact and draining green/brown liquid stool. Bag changed today. Foley intact and draining minimal yellow urine with sediment. Patient is allowed thickened foods but has refused any meals and PO medications so far.\n\nID: Afebrile, on levo abx therapy. ? sepsis due to fungemia. CONTACT precautions.\n\n: Small bed sore on coccyx, duoderm changed today.\n\nSocial: Husband has been updated by this RN and MD.\n\nPlan: Continue to monitor respiratory status. Consider having A-line placed if patient continues to have desating episodes. Plan for tap due to bilateral plueral effusion tomorrow. Encourage patient to eat thickend foods. Have team change PO meds to IV/SC if patient continues to deny food and medication.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-30 00:00:00.000", "description": "Report", "row_id": 1608726, "text": "RESPIRATORY CARE:\nPATIENT COMPLAINING OF SOB AND ASKED TO BE PUT BACK ON THE VENT. ON ARRIVAL RR 24-28 SATS 97%. ALBUTEROL/ATROVENT MDI'S WITH SPACER VIA TRACH GIVEN. PATIENT SUCTIONED FOR SMALL AMOUNTS OF THICK YELLOW. BREATHSOUNDS ARE DECREASED. PATIENT STILL FELT SHE NEEDED TO GO ON VENT. PATIENT PLACED ON MECHANICAL VENTILATION WITH INITIAL SETTINGS OF WITH SPONTANEOUS VOLUMES AROUND 250. PATIENT FELL ASLEEP SOON AFTER BEING PUT ON VENT. SPONTANEOUS TIDAL VOLUMES THIS AM ARE AROUND 350. PS WEANED TO 5CM. PLEASE SEE RESPIRATORY SECTION OF CAREVUE FOR FURTHER DATA.\nPLAN: CONTINUE MECHANICAL VENTILATION OVER NIGHT. PLACE BACK ON TRACH MASK FOR THE DAY.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-30 00:00:00.000", "description": "Report", "row_id": 1608727, "text": "FOCUS; NURSING PROGRESS NOTE\n55 YEAR OLD FEMALE WITH MEDICAL PROBLEMS. SHE HAS BEEN RECENTLY HOSPITALIZED SINCE WITH MESSENTERIC ISCHEMIA. SHE IS S/P COLECTOMY AND ILEOSTOMY. HOSPITAL COURSE COMPLICATED BY RESP FAILURE S/P TRACH AND FUNGEMIA. SHE WAS ADMITTED TO THE MICU WITH MS CHANGE, HYPOTENSION AND TACHYCARDIA. SHE REQUIRED CVVHD AND HAS BEEN WEANED FROM THE VENT FOR AT LEAST MOST OF THE DAY.\nREVIEW OF SYSTEMS-\nNEURO- SHE IS ALERT AND ABLE TO MAKE HER NEEDS KNOWN. MAE. CALM AND COOPERATIVE WITH CARE.\nRESP- TRACHED. TAKEN OFF VENT THIS AM. GOAL IS TO KEEP HER OFF THE VENT IF SHE CAN TOLERATE IT. SHE IS ON A 40% % TM WITH SATS 100%. BS CLEAR DIMINISHED AT THE BASES. SUCTIONED FOR THICK YELLOW TO WHITE SPUTUM.\nCARDIAC- HR 80-90'S. NSR WITH RARE PVC. DID HAVE EPISODE OF AFIB TODAY AT RATE IN THE 80'S WITH SBP IN THE 140'S. DR MADE AWARE. NO TREATMENT ORDERED. CONVERTED BACK TO NSR IN A FEW MINUTES. SBP 130-140. ON LOPRESSOR. STARTED ON HYDRALAZINE AND ISORDIL. HEPARIN DRIP INCREASED TO 850U/HR AT 1500 ONCE OFF CVVHD TO KEEP ANTICOAGULATED FOR AFIB. PTT DUE AT 2100. PHOS LEVEL TODAY 1.1. 15MMOL NA PHOS HUNG TO TREAT THIS.\nGI- ABD SOFT WITH POS BS. HAS TF OF NOVASOURCE VIA DOBOFF FT AT GOAL RATE OF 40CC/HR. NO RESIDUALS FROM FT. ILEOSTOMY WITH BROWN LIQUIDY STOOL THAT IS GUIAC NEG. OF NOTE ILEOSTOMY APPLIANCE DUE TO BE CHANGED TOMMORROW.\nGU- FOLEY PATENT DRAINING YELLOW URINE WITH SEDIMENT AT 15-30CC/HR.\nENDO- ON NPH DOSE OF INSULIN. BS 132-313. TX WITH SS.\nHEME- HCT STABLE AT 28.6.\nID- AFEBRILE. ON CEFTAZ. VANCO TO BE DOSED BY LEVEL PER RENAL SO Q 12 HOUR VANCO DC'D. LEVEL TO BE CHECKED IN AM. OF NOTE TOMMORROW IS THE LAST DAY OF VANCO.\nRENAL- CVVHD CLOTTED. TAKEN DOWN PER RENAL. RENAL TO FOLLOW FOR ? NEED FOR HD. KCL AND CALCIUM DRIPS DC'D ALONG WITH CVVHD.\n HUSBAND IN AND UPDATED BY THIS NURSE.\nDISPO- REMAINS IN THE MICU A FULL CODE.\nPLAN- KEEP ON TC TONIGHT IF TOLERATED.\n MONITOR UO.\n VANCO LEVEL IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-31 00:00:00.000", "description": "Report", "row_id": 1608728, "text": "NPN 7p-7a\nNEURO: Pt had overall good night and slept most of shift. Pt mouthing words to meet needs. No c/o pain, and no issues with anxiety this shift.\n\nRESP: Pt off of vent. Tolerating trach collar well on 40% fio2. LS clear, diminished bases. Suctioning occas. for thick yellow sputum. Sats >99%. RR 15-25.\n\nCV: NSR 80s-90s, occas PVCs. BP 111-140s/40s-60s. Heparin gtt was running @ 850u/hr but held for 1H for PTT>150 and then rate decreased to 500u/hr. AM labs pending.\n\nGI/GU: ABD soft, +BS. Illeostomy draining loose brown stool. TFs @ goal 40cc/hr via post pyloric NGT. U/O has improved over night, foley draining 15-30cc/hr.\n\nID: Pt has been afebrile. Covered on ceftaz and now renally dose vanco per level.\n\nSOCIAL: Pts husband called and updated by this RN.\n\nPLAN: Continue to monitor fluid balance, and renal functioning. Pt will most likely need HD as CVVHD stopped yesterday. Continue trach collar as long as tolerated. Pt most likely will be D/C'd to rehab for further treatment and reconditioning.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-31 00:00:00.000", "description": "Report", "row_id": 1608729, "text": "Resp. Care\nPt. rested comfortably all shift. Pt. sx via nsg. No complaints of sob or anxiety. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-31 00:00:00.000", "description": "Report", "row_id": 1608730, "text": "MICU-7 Nursing Note 7A-7P:\n\nNeuro: Pt. A&O x3, calm and cooperative with care. Tolerated 4hrs with speaking valve. Speech clear and appropriate. Moves extremities strongly.\n\nResp: Trach collar 40% O2. SAT 100%. Lungsounds clear, diminished bases. Strong cough, occasionally needs sx of trach if unable to cough sputum all the way out. Small amounts thick yellow sputum.\n\nCV: NSR rate 80's, SBP 130's. Hydralazine, Amiodarone, Lopressor scheduled for HR/BP control.\n\nGI: Speech/swallow eval today was passed. Pt. is to have speaking valve on to eat. She should avoid mixed liquid/solids such as cereal or noodle soup for now. Feeding tube will remain in place until it is clear that patient will remain off vent and be able to take adequate nutrition PO. Ileostomy draining loose brown stool. Abdomen soft, + BS auscultated.\n\nGU: Foley cath draining adequate amounts cloudy yellow urine. HD cath RSC intact. possible HD tomorrow.\n\nID: afebrile. Ceftazidime 1Gr IV Q24hr for pneumonia. Tacrolimus for immunosuppression post renal transp.\n\nDispo: plan to call patient out to floor when medically cleared, then to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-23 00:00:00.000", "description": "Report", "row_id": 1608611, "text": " \"B\" Admission Note:\n\nPt is 55 year old female who was discharged from after having infarction of colon and ileostomy, complicated by resp failure post-op, trach and failed to wean off vent. Sent to hosp.\n She went to Med Center with fever of 103. Bld and urine were + for fungus. Central line was thought to be source. It was d/c'd and replaced. Treated with Ticarcillin and Caspofungin.\nPt was to return to rehab but today had increasing dyspnea,volume overload, and renal failure. Blood pressure was also elevate. Pt was given 80mg IV Lasix, solucortef and IV NTG with no effect. husband requested transfer back to .\n\nOther PMH: DM,HTN,PVD,Lt BKA,CRF,s/p renal cadaver transplant,ATN, Bilat breast CA,xrt&chemo, MIx2,CABGx2,anemia, gout,Lt eye prosthesis.\n\nAllergies: Codeine,Dilaudid\n\nShe arrived by ambulance on IV NTG. SOB but sats=98% on 4l nc. Crackles noted at bases. Non productive cough. RR=20's. HR=new onset afib with rt BBB, No EKG changes but tropi elevated. C/o chest pain when breathing midsternal with no radiation, 1 s.l. NTG given. Pt was very anxious, relieved with MSO4 and Ativan. She received 120mg IV Lasix here at with u/o=10-15ml/hr.\n\nCVS: Afebrile. HR=76-108 afib with rare PVC's. SBP=163-182. CVP=20-22. IV Heparin drip was started at 1650U/hr after 400U IV Heparin bolus. IV NTG weaned off. Started on Cefipime and Vanco. Some edema of rt leg, difficult to palpate pulses.\n\nResp: O2 4L nc, Received neb rx. Still crackles at bases. Sats=96-98%. Chest xray showed some evidence for pneumonia, started on antibiotics, vanco and cefipime.\n\nGI: NPO, Ileostomy functioning, stoma pink.+BS.\n\nGU: Foley cath, U/O=150ml upon arrival then 10-15ml/hr after receiving total of 120mg IV Lasix. Creat=3.1. Will be having renal consult in am for ?possible dialysis.\n\nNeuro: A&Ox3, Follows commands, moves all extremities but gets mixed up at times when asked questions about medical history.\n\n: Edema noted, bruises all over from being on Heparin and Lovenox, pt states. No open or red areas noted.\n\nPain: Pt c/o midsternal CP when breathing, EKG done, no changes, 1 s.l. NTG given also, 2mg MSO4 with relief. Very anxious, given 0.5mg IV ativan at pt request with good effect. Pt did sleep for part of the night.\n\nSocial: Husband, math professor , spokesperson for pt.\n\nPlan: Renal consult re:?dialysis. IV Heparin,Lasix and antibx. Change central line.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-23 00:00:00.000", "description": "Report", "row_id": 1608612, "text": "NPN 0700-1900:\nEvents: This is a 55 yo lady who presented yesterday for resp. failure, renal failure, and ? fungemia, started on Heparin drip for R/O PE. Today pt was evaluated by surgical, cardiac, medical and renal team, bld cx x2, sputum cx, urine cx and u/a sent to lab, Echo done, US of abdomen and pelvis done revealed gases in kidneys, CT scan of abdomen and pelvis done, echo repeated, given a bolus of 500 ml NS.\n\nROS:\n\nNeuro: Pt is alert, oriented x3, dozing from time to time, looks lethargic, however she answers questions appropriately and cooperates with her care, aware of all what's going on around her, denied any pain or discomfort, yet looks tired.\n\nRESP: Breathing regulary on O2 NC 4 L/min well tolerated RR 17-25, SPO2 96-99%, LS coarse, pt reported SOB from time to time inspite the good SPO2, HO aware.\n\nCV: A-Fib, HR 77-92, BP 130-182/58-82, with LSC line which was inserted in an outside hospital, dressing changed today, IV drip D/Cd, insulin drip started and to be continued even if pt developed hypoglycemia (Dextrose could be given) as per recommendation of diabetic team, peripheral pulses weakly palpable on Rt leg, with Lt BKA, given a bolus of 500 ml NS, no response, echo done, looks puffy, with edema over extremities, started on steroids and antihypertensive drugs, a midline IV is ordered, evaluated by IV nurse.\n\nGI/GU: Started on reg diet appetite is moderate, eats slowly, abdomen obese, BS present, with ileostomy drained 200 ml golden color loose stool, with Foley drained about 10 ml/hr U/O.\n\nInteg: With multiple hematola areas over abdomen and extremities, T max 97.7, on universal precautions.\n\nSocial: Husband and daughter visited and updated on . Pt is full code.\n\nPlan: Continue antibiotics, F/U on culture results, F/U CT abdomen and pelvis result, monitor U/O, CVP, evaluate hydration status, consider CT chest to R/O PE< continue insulin drip and monitor FS hourly, insert midline/PIC line or change central line, continue steroids.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-24 00:00:00.000", "description": "Report", "row_id": 1608613, "text": "55 yr old significant med/Hx presented with resp failure and fungemia Hx of diabetes and currently DKA.\n\nneuro alert oriented but does speak out of context at times Is able to follow commands and know where she is at etc. Anxious at times regarding \"breathing\". Was given 1mg morphine earlier this evening for attempt of a line placement which was unsuccessful. Morphine seemed to ease her anxiety as well as control her labored breathing\n\nResp pt continues to appear to have labored breathing although her sat's RR are wnl. ABG has improved. Pt placed on 40% trach mask for comfort and appears to be more at rest. CT chest showed multiple pleural effusions as well as atletasis.\n\nCVP 70-80\"s B/P would rise at times appearing highest when pt anxious.\nHydrazaline given with good result continues or isordil 50 mg. Pt edematous throughout upper and lower extremities a febrile throughout shift. Glucose levels checked q hr. Have been using LSC line since pt has very slow clotting time. Was given amp of dextrose for B/S of 59. Continues on insulin drip at 1.0. Has varied throughout shift.\n\nGi/GU pt had fluid only this shift. Able to swallow Po without difficulty. HOB @ 90degree Foley in place draining small amt of urine 20-25 with some sediment. B/S are positive ileostomy draining soft brown stool.\n\nPt cont on steriods and hrly glucose checks monitor resp status.\n\nHusband called Dr with him regarding echo results etc. Will be in today to visist with daughter Pt friends in to visist last night.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-24 00:00:00.000", "description": "Report", "row_id": 1608614, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 6.0 sleep apnea tube. Capped most of shift until this AM. Removed cap and placed on 40% cool aerosol d/t increased WOB and accessory muscle use. ABG shows metabolic acidosis. Sxn for thick bloody secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2158-06-24 00:00:00.000", "description": "Report", "row_id": 1608615, "text": "contine from previous note Pt listed as CVp 70-180's should say HR 70-80's Also Ct chest results from yesterday. should be Ct of abdomen\n" }, { "category": "Nursing/other", "chartdate": "2158-06-27 00:00:00.000", "description": "Report", "row_id": 1608626, "text": "NI 0700-1900:\nEvents: Pt is much better today, more responsive, more conversing, SPO2 100%, so put on RA, very good appetite, U/O improved, being dialysed today.\n\nNeuro: Pt is alert, oriented x3, much more conversing appropriately, denies any pain or discomfort.\n\nResp: Breathing regularly on RA, LS CTA, denies any SOB, RR 10-19, SPO2 94-100%.\n\nCV: SB-ST HR 58-70, BP 135-157/54-76, with a left SC line with an extra port for IV use, on NS KVO, insulin drip adjusted according to Q 2 hrs FS that ranged between 132-207, on Fluconazole IV, cefepime D/Cd, peripheral pulses weakly palpable on rt leg, Lt BKA, on antihypertensive drugs.\n\n\nGI/GU: Tolerating redular diabetic diet very well with very good appetite, abdomen obese, BS present, with ileostomy with soft brown stools, Guaiac positive, HO informed, with Foley catheter drained 25-50 cc/hr u/o, on dialysis presently, plan is to remove 2 L.\n\nInteg: integrity is intact, except for bruises over abdomen that pt came from OH with due to Heparin injections in her belly, T max 97, on contact precautions for MRSA.\n\nSocial: Husband called and updated about health condition and , visit in late this evening, pt is full code.\n\nPlan: Monitor pt's breathing pattern and resume NC if needed, monitor electrolytes and BUN/CR and U/O, dialysis as needed, continue Fluconazole, F/U results of cx, continue insulin drip even though pt develops hypoglycemia (give dextrose PRN).\n" }, { "category": "Nursing/other", "chartdate": "2158-06-27 00:00:00.000", "description": "Report", "row_id": 1608627, "text": "BS CTAB, slightly diminished. Remains with tube capped. Weaned to 3L/m and then to room air.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-28 00:00:00.000", "description": "Report", "row_id": 1608628, "text": "NPN-MICU\nMs to recover slowly from her RF\nNeuro:pt to be A&Ox3, MAE and able to sleep on and off.\n\nCV: pt remains stable with BP 130-170's with HR in the 70's SR freq PVC's. She on x3 BP meds. She has no c/o pain\n\nResp:pt on RA with O2 sats of >97%, lungs are clr with non prod cough. She says the HD has helped tremondously with the fluid on her lungs.\n\nGU: pt with very sedimenty urine and u/o of 35cc/hr. Her lytes and CR pnd for am, Should have HD again today for fluid removal\n\nGI/ENDO: Pt on IV Insulin drip at 2u/HR with a BS still all over the place. She ate some crackers when BS at 86. She is passing brown stool via ileostomy\n\nID:pt is afebrile on IVAB\n\nA/P:Will to follow rsp to HD and note labs and u/o\n IV insulin,\n O2 on and off as needed\n" }, { "category": "Nursing/other", "chartdate": "2158-06-28 00:00:00.000", "description": "Report", "row_id": 1608629, "text": "Resp: Pt remains capped with sleep apnea tube on 3 lpm n/c. No distress noted. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-28 00:00:00.000", "description": "Report", "row_id": 1608630, "text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details..\n\nA&O x3. Pleasant and cooperative.\n\nUO adequate. HD on hold until tomorrow.\n\nGd O2sats on RA. No c/o SOB.\n\nStanding Insulin dose started at 1830. Plan to dc Insulin gtt at . Apetite fair.\n\nMultiple visitors in. ? c/o to floor if glucose remians stable off insulin gtt.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-29 00:00:00.000", "description": "Report", "row_id": 1608631, "text": "Resp: Pt remains capped with #6 sleep apnea tube. 02 sats @ 99% on ra. No distress noted. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-20 00:00:00.000", "description": "Report", "row_id": 1608646, "text": "Respiratory Care Note\nPt received on 50% trach mask. BS diminished throughout. MDI's given Q6 with slight improvement in aeration. Speech evaluated pt for PMV. Pt on PMV for 20min, but c/o increased difficulty in breathing. Pt tachypneic at 1pm. ABG's drawn - results within normal limits with good oxygenation. Plan to closely monitor pt at this time.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-20 00:00:00.000", "description": "Report", "row_id": 1608647, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\nPT ALERT, MILDLY ANXIOUS AT TIMES BUT ABLE TO CALM. HYPERTENSIVE IN LATE MORNING, FOLLOWING SPEECH AND SWALLOW EVAL, BECOMING TACHYPNEIC, TACHYCARDIC. C/O SOB, MICU TEAM PAGED AND IN TO EVAL. ABG DONE AND WNL, SUCTIONED FOR VERY LITTLE THICK YELLOW SPUTUM. EKG DONE AND APPEARED UNCHANGED. INCREASED ECTOPY AT THIS TIME, VENT BIGEMINY FOR BRIEF PERIODS, LYTES SENT AND DO NOT NEED REPLETION, CA 1.46, TEAM AWARE. SPEECH AND SWALLOW EVAL DONE AND PASSE MUIR VALVE PLACED HOWEVER, APPEARS TO BE MAKING PT ANXIOUS AND SOB. THIN LIQUIDS TRIED AND VIDEO SWALLOW STUDY RECOMMENDED TO RULE OUT ASPIRATION. WILL NOT TRANSFER OUT TODAY, FAMILY UPDATED. TMAX 100.5\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-21 00:00:00.000", "description": "Report", "row_id": 1608648, "text": "RESP CARE: Pt recieved on 50% TC, tachypneic, breathing paradoxical.VBG WNL. Lungs coarse rhonchi,crackles L lung, /dim, clear on R. Sxd scant amt white sputum. Recieved HFN rx with alb/atr with little effect. Pt placed back on mechanical ventilation for the night. SEE CAREVUE FOR SETTINGS. RR 15-25. RSBI this am 116. Pt placed on PS at 0400 with Vts 400s/RR 20s. Plan is to place pt back on TC this am. Leave vent on standby.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-21 00:00:00.000", "description": "Report", "row_id": 1608649, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: ALERT, EASILY , MOUTHING WORDS, FOLLOWING COMMANDS CONSISTENTLY, MAES. NO C/O PAIN, ATIVAN GIVEN FOR RESTLESSNESS/ANXIETY W/GOOD EFFECT.\n\nCVS: HR 70S-80S, NSR W/FREQUENT PVC'S-PT BASELINE. SBP 110S-160S, UP TO 170S W/ANXIETY, HYDRALAZINE 20MG IV ONCE, LOPRESSOR & HYDRALAZINE ATC GIVEN DECREASE IN SBP TO 110S-120S. HCT 24.6, T-MAX 100.3 AX- GIVEN. PTT 91.3, INR 1.3, HEPARIN DRIP AT 1150 UNITS/HR. POTASSIUM & MAG REPLETED FOR K 3.7, MAG 1.7 THIS AM.\n\nRESP: PT TACHYPNEIC UP TO 40 BPM, USING ACCESSORY MUSCLE, INCREASED WORK OF BREATHING NOTED, MICU RESIDENT AWARE. PT BACK ON VENT OVERNOC TO REST, A/C-VT 500, PEEP 5, 40%. TOL WELL, SLEPT COMFORTABLY MOST OF NOC. PT SUCTIONED FOR SM AMTS THICK, WHITE SECRETIONS, STRONG, PRODUCTIVE COUGH. PRESENTLY ON CPAP+PS-5/15/40%, RR 20'S, UNLABORED.\n\nGI/GU: NGT PATENT, TF AT GOAL(35CC/HR), RESIDUALS 15-120CC, TF HELD INTERMITTENTLY. ILEOSTOMY PATENT W/MOD AMTS LOOSE, BRWN STOOL, HRLY U/O>20CC-MICU RESIDENT AWARE, OK W/LOW U/O.\n\nINTEG: COCCYX COVERED W/LGE ALLAVERT DSG, C/D/I. PT TURNED FREQUENTLY FOR CHECKS, NO NEW AREAS BREAKDOWN NOTED.\n\nENDO: BS COVERED PER SS & STANDING DOSE Q-HS\n\nPLAN: HEMODYNAMIC MONITORING, CPAP/RESP SUPPORT AS NEEDED, TRACH COLLAR AS TOL-? REATTEMPT PASSE MUIR VALVE TRIAL, PAIN MGMT, WND CARE, NUTRITIONAL SUPPORT, FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-29 00:00:00.000", "description": "Report", "row_id": 1608723, "text": "repsiratory care\npt weaned from vent and placed on trach . see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-03 00:00:00.000", "description": "Report", "row_id": 1608676, "text": "NPN 7p-7a\nEVENTS: Pt MS waxes and wains, has not been verbal since initial assessment at . Pt is alert to pain, ut does not f/c or answer to questions. HO aware. Tmax 100.8, pt pan cultured and given 650mg tylenol. Ordered Cefepime and vanco for ? PNA. Awaiting ID aproval. Pt's BS did drop to 33, prob pt receiving insulin while NPO. All insulin held this shift. Pt given juice with good effect.\n\n\nNEURO: Pt is alert to voice, withdraws to pain. Pt has been more lethargic tonight, as stated above. HO aware, continue to monitor. + MAE.\n\nCV: NSR 70s-90s, with occas PVCs. BP 109-150s/40s-60s. Pt getting Hydral/Lopressor. + palpable pulses in right dorsalis.\n\n\nRESP: pt is trached, on .35 % trach mask. Pt has productive cough. Suctioning thick clear secretions. LS coarse, diminished @ bases. Sats>97%. RR 10-20s.\n\nGI/GU: ABD is softly distended, +BS. Illeostomy draining liquid stool. NGT for meds, pt NPO. U/O scant, foley daining clear yellow urine. Pt received HD yesterday.\n\n: Coccyx has stage 2, covered with duoderm.\n\nSocial: husband called and updated by this RN.\n\nPLAN: Awaiting ID approval for new ABX, follow fever curve and f/u with pending cultures. Montior BS. Monnitor MS, holding all sedatives.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-03 00:00:00.000", "description": "Report", "row_id": 1608677, "text": "MICU 7 0700-1900 npn\n\nPlease refer to flowsheet for current objective data and admit note for patient history.\n\nNote: Patient has Left glass eye, and Left below the knee amputation.\n\nNeuro: Patient is alert and oriented to voice, and pain. At times she is confused but is improved from previous shift. +MAE's. MRI of head today, question vegetation on heart valves and concern about veg. travel to brain. Results pending. Pt. denies pain except during a procedure when she spends a significant amount of time on her back.\n\nCV: HR NSR with rare PVC's. SBP 110-150's, pt. remains on hydral/lopressor for BP management. Recent CXR showed CHF, but team noted that there is no current impact on patient cardiac/pulmonary function. R pedal pulses are easily palpable.\n\nResp: Patient remains trach. on 35% humidified TM. LS have been coarse in upper lobes bilaterally and diminished in lower lobes. Pt continues neb. therapy. Neb's are at bedside with spacer. In the event of needing to travel there is tubing already set up at the head of bed. Patient has maintained sat's >95%. Suctioned trach for scant amounts of thin white secretions.\n\nGI/GU: Patient NG tube is intact and in place. Patient is to start TF at 0000 at 10cc/hr. BS are present. Ileostomy bag is intact, stoma is pink, and draining green liquid stool. Foley is intact and draining yellow urine with sediment. Urine spec. sent.\n\n: Stage two on coccyx, covered with dueoderm, turn from side to side q2hrs.\n\nID: Tmax 100.2 rectal, gave tylenol and temp decreased to 99.5 rectal.\nPatient remains on contact precautions for MRSA/VRE? Positive for fungemia. Blood cultures pending. Urine cultures pending. Abx therapy includes caspofungin, vanco and cefepime.\n\nEndo: Last FS 218 covered with 8 units. BS continues to be very labile.\n\nPsych: Patient is very and cries at times. Patient expressed the desire to \"just die\" x3.\n\nSocial: Family in to visit and updated by this RN and Dr. . Husband will call for update at 8-9PM.\n\nPlan: Continue to monitor resp. and hemodynmic status. Suction trach as needed. Start TF at Midnight at a rate of 10cc/hr. Leave at 10cc/hr for eight hours and advance if patient does not present with any s/sx of N/V and minimal residuals. Monitor BS and administer insulin per protocol. ? need for psych consult, patient is having difficulty coping with longterm and prognosis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-04 00:00:00.000", "description": "Report", "row_id": 1608678, "text": "MICU NPN 1900-0700\nNo events overnight.\n\nNeuro: Pt is awake and alert, oriented to person and place. Calm and cooperative with care. Slept well through the night and easily . Denies pain.\n\nCV: HR 70's, SR with occasional PVC's. BP 120's-130's/40's. Afebrile\n\nResp: LS's clear in upper airways, diminished at bases. Non-productive dry cough. Remains on TC with FiO2 35%. Tolerated PMV through most of shift, off while sleeping.\n\nGI: Abd softly distended with +bs's. Ileostomy draining loose green stool, appliance intact. TF's started via NGT last night, Nepro at 10cc/hour. No order to advance rate at this point. Pt had been tolerating regular diet prior to transfer to unit on .\n\nGU: Pt with yeast in her urine. Was to have foley changed, but after discussion with HO, foley was removed given that pt is oliguric.\n\n: Duoderm to coccyx intact. No other breakdown noted, turned and repositioned through the night. Rt IJ with dialysis catheter leaking serosang drainage, dressing changed, however, it continues to leak. Rt AC with PICC line, dressing and site clean and dry.\n\nEndo: pt's BS down to 58 last pm. Rec'd amp D50 and BS up to 106. Rec'd scheduled dose of glargine at 2330 MD recommendations.\n\nSocial: pt's spoke with her husband on the phone last eve.\n\nPlan: to monitor VS's, I&O, labs, resp status and mental status. Scheduled to have HD today.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-04 00:00:00.000", "description": "Report", "row_id": 1608679, "text": "RESP CARE: Pt remains on 35% TC all shift. PMV removed at 2200/ ^cc air placed in cuff to maintain Cuff pressure 25cmH20. Atrvovent MDI given with little effect noted. Lungs dim bibasilar.Sxd scant amt white sputum. Pts cuff deflated this am and placed back on PMV.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608703, "text": "FOCUS; ALTERATION IN RENAL STATUS\nRENAL- ON CVVHD TAKING OFF 50CC/HR. TO RECEIVE PRISMINATE FOR DIALYSATE AND REPLACEMENT FLUID. BP HAS TOLERATED THIS ALL DAY. SYSTEM JUST CLOTTED AND WAS TAKEN DOWN. ON K AND CA DRIP. LATEST K 4.2 WILL BE PLACED ON 10MEQ KCL IN 100CC AT 20CC/HR AND CA 20GM IN 500CC AT 30CC/HR ONCE CVVHD RESUMED. MG WITH LAST SET OF LABS WAS 1.6. PHOS 1.0. DR MADE AWAREWILL ORDER IV REPLACEMENT. AFTER AMIODARONE FINISHES WILL NEED TO GET ANTIBIODICS, MAG,THEN K PHOS.\nPLAN- RESUME CVVHD.\n NEXT SET OF LABS DUE AT 2300.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608704, "text": "Respiratory Care\nPt remains trached and on vent support. No vent changes were made during shift. Lung sounds were course and dim in the bases. Pt was suctioned for moderate amounts of thick white secretions. MDI's were given as ordered. No ABG's were drawn during shift. Care plan is to continue current therapy. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608705, "text": "focus; addendum\nrenal- ptt at 1100 33.2. heparin drip increased to 600u/hr. repeat ptt result pending.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 1608706, "text": "Resp Care Note:\n\nPt trached on mech vent and CAVH as per Carevue. Lung sounds coars esuct sm th off white sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. mech vent support/PSV.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 1608707, "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 55 Y/O PT WITH MULTIPLE MEDICAL PROBLEMS INCLUDING GOUT, ANEMIA, BILATERAL BREAST CA S/P LUMPECTOMY, S/P XRT/CHEMO, MESENTERIC ISCHEMIA WITH COLECTOMY IN , RESPIRATORY FAILURE S/P TRACH , CRF S/P RENAL TX , PVD S/P L BKA, MI X 2 AND CABG X 2. PT HAS HAD MULTIPLE ICU ADMISSIONS BETWEEN MICU EAST AND REHAB AND OSH SINCE , MOST RECENTLY READMITTED TO MICU7 ON FROM FLOOR WHEN SHE WAS NOTED TO HAVE DEVELOPED MS CHANGES IN COMBINATION WITH HYPOTENSION NAD TACHYCARDIA. CVVHD INITIATED ON WITH GOAL OF REMOVING FLUID TO ALLOW VENT WEAN. HOSPITAL COURSE HAS BEEN COMPLICATED WITH LABILE BLOOD SUGARS IN RELATION TO REPLACEMENT FLUID CHANGES- AS HIGH AS 900'S AT ONE POINT- D/T PT'S RENAL FAILURE- MICU TEAM HAS BEEN TOLERATING HIGHER BLOOD SUGARS TO 300 AND COVERING WITH SLIDING SCALE. CONSULTING- WOULD PREFER TO NOT HAVE INSULIN GTT.\n\nNEURO: PT ALERT AND ORIENTED X . FOLLOWS COMMANDS, ABLE TO MAE X 3 (LT BKA) WITHOUT DIFFICULTY. ATTEMPTS TO ASSIST WITH TURNS AND PERSONAL CARE. ABLE TO MOUTH WORDS WITHOUT DIFFICULTY AND EXPRESS NEEDS. OF NOTE, PT HAS LT GLASS EYE- RT PUPIL IS 3/BRISK. AFEBRILE. TEMPS 97-98- HAS BEEN REQURING BAIR HUGGER INTERMITTENTLY. NO SEIZURE ACTIVITY NOTED.\n\nRR: TRACHED. TRACH IS MIDLINE AND SECURE. PT TOLERATED TRACH CARE WITHOUT DIFFICULTY. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS AND DIMINISHED TO THE BASES. BILATERAL CHEST EXPANSION NOTED. SUCTIONING FOR MODERATE AMOUNT OF THICK, WHITE SECRETIONS. PT HAS VERY STRONG COUGH EFFORT. SP02 > OR = TO 95%. RR 15-20. CPAP/PS 10/5/40%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR-ST, HR 90-100'S- TOLERATED BEING WEANED OFF OF AMIODARONE GTT- CURRENTLY ON PO FORM. DENIES ANY CHEST PAIN. PT HAD BEEN HAVING CHEST PAIN RELIEVED BY SL NITRO AND MORPHINE. CARDIOLOGY HAS BEEN CONSULTING. FEEL THAT ELEVATED CARDIAC ENZYMES AND TROPONIN LEAK ARE RELATED TO DEMAND ISCHEMIA AND NOT A NEW MI. OF NOTE, PT HAS AN EF OF 25%. PALPABLE PULSES NOTED TO BILATERAL RADIALS. PT HAS ONE PICC LINE TO LT ARM. VERY DIFFICULT IV STICK- TEAM WILL NOT PUT IN CENTRAL LINE DUE TO RISKS OUTWEIGHING BENEFIT. CURRENTLY ON HEPARIN GTT TO MAINTAIN CVVHD PATENCY- CURRENTLY AT 300U/HR. NO OBVIOUS SIGNS OF BLEEDING. PT HAS HAD TOTAL OF 30MMOL SODIUM PHOSPHATE, 4GMS OF MAG, CONTINUES ON CA AND POTASSIUM GTTS- TITRATING AS PER CVVHD PROTOCOL.\n\nGI: ABD IS SOFT, DISTENDED AND NON-TENDER TO PALPATION. PT HAS RED AND PATENT STOMA- BROWN, LIQUID STOOL NOTED- GUIAC PT STARTED ON LANSOPRAZOLE. DOBHOFF IS SECURE AND PATENT- RECEIVING GOAL RATE OF 40CC/HR NOVASOURCE PULMONARY TF. DENIES ANY N/V. IN THE PAST, PT HAS RESPONDED WELL TO PRN ANZEMET FOR N.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. ANURIC- WHAT LITTLE URINE SHE DOES MAKE IS YELLOW AND CLEAR. ONGOING CV\n" }, { "category": "Nursing/other", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 1608708, "text": "NURSING PROGRESS NOTE 1900-0700\n(Continued)\nVHD AT BEDSIDE. GOAL IS TO REMOVE -50CC/HR. PT HAS BEEN TOLERATING. TEAM WOULD LIKE TO BE AGGRESSIVE AS POSSIBLE WITH ACHIEVING THIS- WILL CONSIDER INITIATING NEO GTT IF NECESSARY IN AN ATTEMPT TO REMOVE FLUID. PT HAS BEEN TOLERATING FLUID REMOVAL WITH NO PRESSERS. CHANGED AT 1800.\n\nINTEG: DUODERM TO COCCYX IS SECURE AND PATENT. NO OTHER SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. GENERALIZED PITTING EDEMA.\n\nSOCIAL: VERY CONCERNED HSUBAND. ALL QUESTIONS ANSWERED. HUSBAND IN NEED OF GOOD DEAL OF EMOTIONAL SUPPORT. SOCIAL SERVICES IS INVOLVED.\n\nPLAN: ELECTROLYTE REPLETION, HEPARIN GTT TITRATION AS PER CVVHD PROTOCOLS. NEXT SET OF LABS (LYTES, PTT, VBG, GLUCOSE) ARE DUE AT 1000. ATTEMPT TO WEAN VENT AS PT WILL TOLERATE. CONTINUE TO REMOVE -50CC/HR- WILL CONSIDER INITIATION OF NEO GTT IF NEEDED. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2158-08-29 00:00:00.000", "description": "Report", "row_id": 1608724, "text": "Nursing Note: 0700-1900\nNo significant events as of 1700.\n\nNEURO: Alert/following commands and making needs known. MAE. Denies pain. Cough intact.\n\nRESP: Tolerating trach mask with humidified O2 @ 40% maintaining sats @ 100%. RR teens - 20s. No c/o SOB. LS clr/diminished at bases. Sx via trach for small - mod amt of mostly clr secretions. Unable to effectively clear own secretions and will request sx.\n\nC/V: Remains on CVVHD tolerating PFR of negative 100. Goal of negative 500-1L but currently at 1.4L negative; team aware and will continue with current PFR and will reassess if negative 24 hr balance reaches 2L. HR in/out of afib, 90s-100s, occasional PVC. Few remote episodes of beat runs of V tach (?) SBP stable 120s-140s; Lopressor dosing restarted for rate control. Calcium/Kcl/Heparin gtts per CRRT SS. Perihperal edema decreased per team. Cardiology consulted for low EF; will continue with medicinal intervention only.\n\nGI/GU: TF at goal rate 40cc/hr via pedi ngt. Abdomen soft, present sounds. Ileostomy active for liquid, brn stool. U/O 5-15cc/hr.\n\nENDO: SS Humalog changed; followed by . NPH dosing increased to .\n\nID: Afebrile. Covered with Vanco. Warming blanket on for patient comfort.\n\nACCESS: Right SCL dialysis cath; left antecubital dbl PICC.\n\nDISPO: Full code; micu green; husband in and updated by team/RN.\n\nPLAN: Continue CVVHD with possibility of discontinuing tomorrow and attempting HD as BP now stable; continue with SS insulin; contact precautions; next CRRT labs @ 2200.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-26 00:00:00.000", "description": "Report", "row_id": 1608670, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT, ORIENTED TODAY, FOLLOWING COMMANDS\nCV: AFEBRILE. TO HAVE FREQUENT PVC'S TODAY.\nRESP: TRACH COLLAR AT 50%, SAT 100%. BS COARSE. SX FOR SM AMTS THIN WHITE SECRETIONS Q4HRS. PASSEY MUIR VALVE IN PLACE ALL DAY.\nGI: SPEECH AND SWALLOW STUDY DONE- PASSED PER RADIOLOGY. TF D/C'D, NGT D/C'D. PT TO START ON HEART HEALTHY DIABETIC DIET. ABD SOFT, ILEOSTOMY PATENT AND DRAINING LOOSE BROWN STOOL\nGU: LASIX 40MG IV GIVEN TODAY HUO ADEQUATE\nENDO: BS . TO BE LABILE. 1600 BS 51- PT GIVEN 180CC APPLE JUICE.\n: ALLEVYN DRESSING CHANGED OVER COCCYX. AREA PINK AND HEALED, SM TEAR FROM TAPE ON UPPER RIGHT BUTTOCK.\nA/P: TRANSFER TO FLOOR WHEN BED AVAILABLE, ADVANCE DIET AS TOL, ASPIRATION PRECAUTIONS. . TO MONITOR BS CLOSELY AND FOLLOW SLIDING SCALE.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-26 00:00:00.000", "description": "Report", "row_id": 1608623, "text": "NPN 07--1900:\nEvents: A dialysis LSC central line with and extra port for IV use was placed yesterday (under guidewire) and pt was dialysed today, transfused today with 2 units of blood for decreased Hct.\n\nROS:\n\nNeuro: Pt is alert, oriented x 3, answers questions appropriately, denies any pain, looks lethargic, follows commands consistently, opens eyes to verbal stimuli, Artificial tears applied.\n\nResp: Reathing regularly on O2 NC 3 L/min, RR 9-14, SPO2 99-100%, LS CTA, with tracheostomy stoma, trach care done, coughing and expectorating clear whitish secretions.\n\nCV: SB-NSR HR 57-79, HR 132-159/48-66, peripheral pulses weakly palpable in rt leg (with Lt BKA), with lt SC line on insulin drip 0.5-2 units/hr, FS checked Q 2 hrs 140-266, blood cx taken, transfused with 2 units of bld transfusion, given one dose ov Vancomycin, receiving Fluconazole, cefepime and hydrocortisone in addition to PO antihypertensive drugs.\n\nGI/GU: Eating regular diabetic diet well tolerated, though eats slowly, BS present with ileostomy passing brownish to dark soft BM, ileostomy care done and bag changed, Guiac positive, HO informed, HD done, with Foley draining minimal yellowish cloudy u/o.\n\nInteg: With bruises over abdomen could be from injections, T max 96.5, pt is on contact precaution due to MRSA (in blood).\n\nSocial: Husband called twice and updated on pt's condition, will visit in later this evening, pt is full code.\n\nPlan: Continue antihypertensive drugs, antibiotics, antifungal, and steroids, monitor FS Q 2 hrs and continue insulin drip on even if hypoglycemia develops (can give Dextrose PRN), monitor BUN/CR, electrolytes and CBC, transfuse as needed, send Vancomycin trough in am (could be sent with morning labs), take bld cx daily.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-27 00:00:00.000", "description": "Report", "row_id": 1608624, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 6.0 sleep apnea tube capped on 3lpm O2. Tolerating well.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2158-06-27 00:00:00.000", "description": "Report", "row_id": 1608625, "text": "MICU NPN 7P-7A\nNEURO: ALERT AND ORIENTED X3. DID NOT SLEEP WELL. C/O LEFT SCAPULA PAIN AFTER TURNING THIS MORNING. GIVEN 650MG TYLENOL.\n\nCARDIAC: HR 58-68 SR WITH OCCASIOANL PVC'S. BP 131-168/49-82. CONTINUES ON HYDLAZINE, ISORDIL, LOPRESSOR, AND CLONIDINE. HCT STABLE. 30.\n\nRESP: ON 3L N/C WITH RR 10-12 AND SATS 98-100%. LS CLEAR WITH DIMINISHED BASES. NO COMPLAINTS OF SOB.\n\nGI/GU: ABD SOFT AND OBESE WITH +BS. BROWN LIQUID STOOL VIA ILEOSTOMY. ~260CC OF AMBER/YELLOW URINE WITH SEDIMENT. CREAT 3.9 ?HD TODAY.\n\nFEN: LYTES PER CAREVUE. INSULIN GTT 0.5-3U/HR WITH BS 68-145. EATING AND DRINKING WITHOUT DIFFICULTY.\n\nID: TMAX 96.5 WITH WBC 16. ON FLUCONAZOLE AND CEFEPIME. SENT ONE SET OF BLOOD CX. ON CONTACT PRECAUTIONS FOR MRSA. VANCO LEVEL 32.\n\n: W/D/I.\n\nACCESS: LSC DIALYSIS CATH.\n\nSOCIAL/DISPO: DNR. HUSBAND IN LAST EVENING. POSSIBLE HD TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-26 00:00:00.000", "description": "Report", "row_id": 1608671, "text": "Resp Care\n\nPt remains trached with #6 DIC portex wearing PMV tol well with spo2 99% RR 18-22 on 50% trach collar. BS essentially clear with scatterred exp wheezes heard at times which is relieved with bronchodilators. No sxing done by RT this shift as pt is able to expectorate most secretions on own. Humidifier bottle refilled and water trap drained. WIll to monitor per airway protocol.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-27 00:00:00.000", "description": "Report", "row_id": 1608672, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Pt had a very uneventful night. Slept through most of night. Neuro exam remains unchanged. C&DB with instruction, coughing and raising small amounts of thick white sputum. Did not require much suctioning. Blood sugars remain labile, following s/s.\n\nPlan:\n Call out to floor\n Montior blood sugars and treat protocol\n Pulm toileting\n Provide pt and family with emotional support\n" }, { "category": "Nursing/other", "chartdate": "2158-08-02 00:00:00.000", "description": "Report", "row_id": 1608673, "text": "MICU 7 NPN:\nPt. alert this am and passy muir valve put on by resp. due to pt. trying to communicate. She is A&Ox3 and c/o being very anxious with RR high 30s. Given 1mg ativan but continues anxious- continue to monitor. Husband called again this am and will be in to visit later today.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-02 00:00:00.000", "description": "Report", "row_id": 1608674, "text": "MICU 7 NPN:\nPt is 55 y/o female with CRI s/p renal transplant , PVD, DMI, renal failure now with fungemia, hypercalcemia. Unknown source of fungemia although TEE showed possible vegetation- on caspofungin. transferred from CC7 at 0130. Pt. with persistenst fungemia and hypercalcemia admitted to ICU for decreased MS, vomitting, tender abd. requiring CT scan, elevated LFTs, tachypnea and need for closer monitoring. Appears to be pancreatitis- abd. CT neg. for mescenteric ischemia. PO2 on 40%=70.\nNEURO: Lethargic on arrival and to stimulation. More alert this am and nodding to questions appropriately. Follows commands. Moving all extremities in bed. Complaining of pain in abd. on palpation but otherwise doesn't appear to be in pain. Stating to resp. this am, by use of passy muir valve, that she is \"seeing bad men on the wall.\" Reoriented and continues anxious. Will refrain from using ativan due to decreased MS. Continue to monitor.\nCV: Afeb. Urine cx and sputum cx sent. Bld. cxs sent on flr. HR 80s-90s SR with BBB. SBP 170s- hydralazine given 20mg x1. warm and dry with palp. pedal pulses to RLE. R AC double lumen PICC intact and plan to pull today and cx with new one to be placed.\nRESP: On 40% humidified TM with O2 Sat >95%. LS diminished throughout. RR 20s-30s. Trach intact (cuff inflated) with trach care done. Sx'd for frothy white secretions in small amts. Strong cough and clearing some secretions out of trach.\nGI/GU: Abd. soft, distended and tender to palpation. No bowel sounds heard. Illeostomy draining small amts liquid green stool. No nausea or vomitting. NPO. Foley draining about 10cc/hr of yellow urine with sediment. Plan for placement of new Quinton cath. today and pt. to receive HD afterwards.\n: Stage 1 ulcer to coccyx with duoderm applied. Repositioned side to side. Picc line to R AC intact and good blood return. L BKA intact.\nOTHER: Husband called and updated on pt's condition and plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-02 00:00:00.000", "description": "Report", "row_id": 1608675, "text": "MICU 7 0700-1900 NPN\n\n55 yo female with CRI s/p renal transplant in , renal failure now with fungemia, hypercalcemia. source of fungemia although TEE showed possible vegetation-caspofungin. Transferred from CC7. Patient has persistant fungemia, and hypercalcemia and presented to MICU 7 with decreased MS, vomitting, tender abd. elevated LFTs, tychypnea. CT scan negative for mescenteric ischemia. Team questions pancreatitis.\n\nPlease refer to flowsheet for all objective data.\n\nNeuro: Patient has been very lethargic this shift. However, patient does answer questions appropriately when she is awake and has been oriented x3. Pt. has a weak lift and hold response to all four extremities. Denies pain except when coughing patient states that coughing makes her abd. hurt. Patient is able to verbally communicate when valve is in place.\n\nCV: HR is 80-90's NSR with rare PVC's. SBP 130-150's, Pedal pulse in right leg is palpable. Patient continues to be on lopressor and hydralazine for hypertension. R double lumen PICC was pulled and replaced by IR. Temporary HD line placed. HD pulled off 2 liters. Pt tolerated HD well.\n\nResp: Patient remains trach. on 35% humudified TM. O2 sats maintained at >95%. LS are diminished throughout. Scant secretions suctioned when patient asked to cough. Patient has a strong cough and is able to move secretions.\n\nGI/GU: Patient is currently NPO due to questionable MS. medications have been held. BS are hypoactive, illeostomy remains in place draining green liquid stool. No episodes of N/V this shift. Team plans to place NGT if patients MS . Foley is intact and draining in adequate amounts of clear yellow urine. Urine output total for this shift has been 30cc.\n\n: Stage one on coccyx, duoderm in place. Repositioned patient side to side except during HD per HD request.\n\nSocial: Husband called and was updated by this RN.\n\nPlan: Continue to monitor respiratory and hemodynamic status. Suction if appropriate, continue to encourage patient to move secretions via cough. Monitor urine output. Continue with neruo assessments and notify team of any changes. Plan for possible placement of NG tube. Follow up on labs and cultures sent.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-24 00:00:00.000", "description": "Report", "row_id": 1608697, "text": "ADDENDUM\n0615- PT C/O 8/10 CHEST PAIN. SL NITRO ADMINISTERED, EKG OBTAINED, DR. INFORMED. PT HAD SOME RELIEF WITH SL NITRO, HOWEVER AT 645- HAD ANOTHER ONSET OF CHEST PAIN - DR. AGAIN NOTIFIED. ANOTHER SL NITRO ADMINISTERED AS WELL AS 1MG MORPHINE IVP WITH THERAPEUTIC RESULTS. ION CA LEVEL ALSO SIGNIFICANT FOR BEING 0.9- DR. MADE AWARE- NO FURTHER INTERVENTION AT THIS TIME. WILL NEED TO CONTINUE TO FOLLOW. IN LIGHT OF EPISODE OF CHEST PAIN AND ADMINISTRATION OF 2 SL NITRO AND MORPHINE- AM CURRENTLY RUNNING CVVHD EVEN AND CLOSELY MONITORING. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2158-08-24 00:00:00.000", "description": "Report", "row_id": 1608698, "text": "NPN\n\nBriefly: Pt went into afib and dropped her BP, we have not taken any fluid off since this event, receiving blood for a HCT of 26, lytes have been replaced throughout the day.\n\nNeuro: Pt is drowsy but easily arousible and oriented x3. Asking some questions about what went on today and also asking for things like a blanket or to be suctioned. Her paxil was increased today.\n\nCV: Her HR was ~115 this morning with a BP ~ 105/50. At 10am she went into rapid afib to the 150s, her BP was 50/palp, we stopped removing fluid with the CVVHD and we gave her 500cc NS back, and she was started on neo. I was able to eventually wean the neo off this afternoon and she has not required any further fluid boluses. She will be started on IV amiodorone this evening. Her CPK/MB/trop to be trended, CPK was 67/40 - MB not done, trop awaiting results from 4pm, 8am was .23.\n\nResp: LS coarse to clear, diminished at the bases bilat. Sx ~ q3 hrs for thick yellow sputum. No changes were made on the vent.\n\nGI: Remains on TF, she is now at her goal of 40cc/hr, she has had periods of n/v for which she has been given anzemet. She had 250cc of very loose stool. Her stoma is pink, her iliostomy bag was changed today. She was ordered for and ABD CT for ? infection since this may be a septic picture - she was too unstable to go today.\n\nGU: The CVVHD has not removed any fluid since 10 am when she went into rapid afib and she dropped her BP, she is currently 560cc pos since MN and 1300cc pos for LOS. Her Lytes have been off today, phos was 1.6 but then came back at 3.0 without intervention, her Na was 126 but returned at 131. She conts on and off Ca gtt and pot has been decreased some today. Her u/o has decreased to 0 for much of the day, she has been doing 15-20cc/hr this morning. - she needs a urine clx.\n\nEndo: Her blood sugar conts to be labile, she was put on q4 hr FS just to monitor her BS but not to cover her with insulin for this. She remains on NPH in the morning only as well as QID humalog coverage.\n\nHem: HCT was 26 - she is receiving a unit of PRBC - she will need a post transfusion HCT.\n\nSoc: Her husband was in today for 4 hours, he is clearly very attached to her and very worried. He told me that he wants everything to be done but also says that he sees the trend and it is not good, he also does not want her to be in pain. He said that his daughter said to him that she has had 55 great years but that she is quite sick. I confirmed that she is very ill and that we are concerned about her. She has multiple systems wrong with her, we are doing everything we can for her but things are not improving steadily.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608699, "text": "Resp Care Note:\n\nPt trached and on mech vent and CAVH as per Carevue. Lung sounds coarse suct mod th off white sput. MDI given as order. Pt in NARD on current vent settings; no vent changes required overnoc. PSV.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608700, "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\nNEURO: PT IS ALERT AND ORIENTED X 3. ABLE TO FOLLOW COMMANDS WITHOUT DIFFICULTY. MOUTHS WORDS SUCCESSFULLY- EASY TO PT ABLE TO COMMUNICATE HER NEEDS WITHOUT DIFFICULTY. ATTEMPTS TO ASSIST WITH TURNS AND PERSONAL CARE. PT HAS GLASS LEFT EYE- RT PUPIL- 3/BRISK. AFEBRILE. COMFORTABLE WITH BAIR HUGGER- TEMPS HAVE BEEN IN THE 97-98 RANGE. ABLE TO MAE X 3 WITHOUT DIFFICULTY. NO SEIZURE ACTIVITY NOTED.\n\nRR: TRACHED. TRACH IS MIDLINE AND SECURE. PT TOLERATED TRACH CARE WITH NO UNTOWARD INCIDENT. BBS= ESSENTIALLY CLEAR TO COARSE- SUCTIONING FOR THICK, WHITE SECRETIONS IN SMALL TO MODERATE AMOUNTS. STRONG COUGH EFFORT. ABLE TO EXPRESS WHEN SHE NEEDS TO BE SUCTIONED. BILATERAL CHEST EXPANSION NOTED. CPAP/PS 10/40%/5. RR 20-25. PT HAS NO C/O SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. PT INITIALLY IN AFIB WITH HR TO THE 130'S. AMIODARONE GTT INITIATED AFTER BOLUS. PT HAS BEEN TOLERATING WELL. GTT TO BE DC'D AT THIS EVENING (). RARE PVC'S NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PT HAS CONVERTED TO SINUS RHYTHM. CARDIOLOGY IN TO RECONSULT- OF NOTE, PT'S EF IS 25%. PT HAS HAD CARDIAC ENZYMES THAT HAVE BEEN TRENDING UP AND TROPONIN LEAK- AT THIS TIME THOUGHT TO PERHAPS BE DUE TO DEMAND ISCHEMIA. PT HAS NOT C/O CHEST PAIN THIS MORNING. IN THE PAST- SHE HAS REQUIRED SL NITRO AND MORPHINE FOR HER CHEST PAIN. PT RECEIVED TOTAL OF 40MEQ K FOR DECREASED LEVELS R/T CHANGES IN REPLACEMENT FLUID. CURRENTLY CONTINUES ON POTASSIUM GTT WITH CVVHD SLIDING SCALE. PT IS ALSO ON CA GTT- TITRATING AS PER CVVHD SLIDING SCALE. PT IS ALSO ON HEPARIN PTT IS CURRENTLY THERAPEUTIC. NO OBVIOUS SIGNS OF BLEEDING NOTED. TEAM TOLERATING CRIT OF 25.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. DOBHOFF IS SECURE AND PATENT. PROPER POSITIONING VERIFIED. PT CURRENTLY RECEIVING NOVASOURCE TF AT GOAL RATE OF 40CC/HR. PT HAS NOT C/O N/V- ALTHOUGH IN THE PAST HAS REQUIRED ANZEMET. ILEOSTOMY IS SECURE AND PATENT. BROWN, LIQUID STOOL NOTED.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. ANURIC. WHAT LITTLE URINE PT MAKES IS YELLOW AND CLEAR. ONGOING CVVHD AT BEDSIDE. CHANGED AT 0100. PT HAS HAD MULTIPLE CHANGES TO REPLACEMENT FLUID FOR ELECTROLYTE IMBALANCES. PT DROPPED SODIUM TO 125. PRISMASATE CHANGED TO BICARB IN D5, HOWEVER, PT'S GLUCOSE LABILE WITH CHANGE- GLUCOSE AS HIGH AS 900'S. HAS SINCE BEEN SWITCHED BACK TO PRISMASATE AND BLOOD GLUCOSE LEVELS ARE TRENDING DOWNWARD. PT HAD BEEN RUNNING POSITIVE D/T NOT BEING ABLE TO TOLERATE ANY FLUID BEING TAKEN OFF- ABLE TO RUN PT EVEN AT BEGINNING OF SHIFT- AT 0200- BEGAN PULLING OFF GOAL OF 50CC/ PT HAS BEEN TOLERATING WELL. PLAN IS TO ATTEMPT TO PULL OFF AS MUCH FLUID AS POSSIBLE AND TEAM IS WILLING TO USE NEO GTT FOR BLOOD PRESSURE CONTROL\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608701, "text": "NURSING PROGRESS NOTE 1900-0700\n(Continued)\nIN ORDER TO ACHIEVE THIS GOAL- THUS PT HAS BEEN TOLERATING FLUID REMOVAL WITHOUT NEED FOR PRESSER.\n\nENDO: VERY LABILE BLOOD SUGARS. AS PER MICU TEAM- DID NOT WANT HIGH BLOOD GLUCOSES TREATED AND THEY WOULD TOLERATE LEVEL AS HIGH AS 300. HOWEVER, AT 2400- PT 400- WAS TREATED WITH 11U REG INSULIN AS PER SLIDING SCALE. DR. AWARE- D/T RENAL FUNCTION- MICU TEAM DID NOT WANT TO INITIATE INSULIN GTT AND WOULD CONTINUE TO TOLERATE HIGHER BLOOD GLUCOSE LEVELS. WHEN REPLACEMENT FLUID WAS SWITCHED TO D5 AND PT'S GLUCOSE LEVELS REACHED 900- THIS WAS VERIFIED TWICE- AT THIS POINT, D5/BICARB WAS DC'D AND INSULIN GTT INITIATED. PT 20U REGULAR INSULIN. D/T PT'S LABILE HX- HAVE BEEN MONITORING PT VERY CLOSELY AS SHE HAS A HIGH PROBABILITY OF BOTTOMING OUT HER SUGAR. THUS FAR, SHE HAS STARTED TRENDING TOWARDS BLOOD GLUCOSE LEVELS IN THE 300'S. INSULIN GTT IS CURRENTLY AT 8U/HR AS GUIDELINES- WILL TITRATE AS NEEDED.\n\nINTEG: DUODERM TO COCCYX IS SECURE AND INTACT. NO OTHER SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. PT HAS GENERALIZED PITTING EDEMA.\n\nSOCIAL: VERY INVOLVED AND CONCERNED HUSBAND. SPOKE WITH HIM ON PHONE TWICE THIS EVENING RE PT'S CONDITION. ALL QUESTIONS ANSWERED. NO ISSUES.\n\nPLAN: MONITOR BLOOD SUGARS. TITRATE INSULIN GTT AS PROTOCOL. MONITOR ELECTROLYTES AND PTT. NEXT SET OF LABS IS DUE AT 1000. PT WILL NEED VANCO DRAWN AT 8AM AS WELL PLEASE. GOAL IS TO REMOVE 50CC/HR AS PT WILL WILL USE NEO AS NEEDED IN ORDER TO ACHIEVE THIS. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 1608702, "text": "Nursing Note 0700-1900\nADM DX: This is a 55 YO female who presented with dyspnea, increased renal failure, volume overload, and fungemia related to TPN administration. She became lethargic and disoriented, dropped SBP to70's and desated to 70's. Question sepsis and sent to MICU for wok-up.\n\nNEURO: Pt. is A+O X 2, no c/o pain. PERRL 2+, has spontaneous movement and follows commands.Pt responds aproppriately to stimuli and MAE'S, with equal hand grasps. Halodol changed to q hs. qtc was .47 today by ekg up from .42. qtc needs to be checked prior to next dose.\n\nRESP: Pt. is currently on CPAP-PS 5/10/40% tv 650. LS coarse in the R and L upper, diminished in the lower bilat.Pt. responded well to chest PT with moderate amounts of thick white sputum.\n\nCV: S1S2 heard upon auscultation, HR 97-106, NBP 116/52-144/52 mean 70-114. NSR with no ectopy noted. Phosphorus 1.8-1.1 Dr. notified n/o neutra-phos 3 packets. Amiodirone 0.5 mg/min at present. To be dc'd at . n/o for po this evening.\n\nACCESS: L PICC double lumen patent CDI L quintin double lumen, for dialysis, pattent CDL.\n\nGI: Ileostomy draining liquid brown stool, stoma red surrouding intact, positive guiac. Placed on lansoprazole due to guiac pos stools. Abd ct scan ordered yesterday was d'cd today due to patient's overall improvement.\n\nGU: Foley draining yellow urine with sedament. Foley care given intact.\n\n: Duoderm to coccx intact, warm and dry.\n\nID: Pt. afebrile, last dose of fluconazole due tonight at . Vanco trough 18.6 vancomicin 1gm ordered to be given when IV amiodarone is finished. on ceftaz.\n\nENDO: Pt. on insulin gtt this AM D/C'd 0900 forglucose of 45 Dr. notified n/o D50 ampule given. 1000 glucose 54 D50 ampule given. Given 5 u nph at 1100. N/O insulin sliding scale. Hydrocort decreased today to 50mg\n\nHEME- 25.5 this am. Checked x2 today 27.4 and 26.6.\n\nprophylaxis- started on sc heparin today as heparin she is oniv is for in cvvhd. on lansoprazole \n\nSOCIAL: Pt. husband into visit updated on wifes condition by this nurse.\n\nDISPO full code.\n\nPLAN: Continue cvvhd at present goal of negative 50cc's/hr. Begin titration of steroids. Continue to monitor fluid and electrolytes, and vent wean as tollerated.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-19 00:00:00.000", "description": "Report", "row_id": 1608641, "text": "Neuro: Pt alert and oriented to self, Opens eyes to voice,follows directions without difficulty. Mouthing words and able to make needs known. Denies pain.\nCV: afebrile, HR 60-70's NSR with occasional PVC's. SBP 110-150'S. Extremities warm. Heparin gtt continues running at 1250 most of night changed to 1050 at 0600 for PTT 113.\nRESP: lungs clear No vent changes overnight. Occasional suctioning required for thin white secretions. O2 sats >98%.\nGI: started on Nepro via NGT. Ileostomy draining large amounts of liquid golden stool.\nGU: foley draining minimal amounts of clear yellow urine.\nENDO: blood sugars 177 last eve recieved insulin, this am sugar 56, recieved amp of D50.\nPlan: Continue to wean vent, Monitor blood sugars.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-19 00:00:00.000", "description": "Report", "row_id": 1608642, "text": "Nursing Update.\nSee flowsheet for specific info\n\nPt alert and oriented, follows commands and MAE's. Tylenol given for neck pain with effect this a.m. NSR with occassional PVC noted, SBP 115-140. 1 unit of PRBC given per MICU team for low crit, will recheck 3 hours after transfusion. Pt on Heparin gtt. On trach mask today, sating 100% on 70% O2, tolerating well, no distress noted. Sux'd for small amount of thick white sputum. Pt has strong prod cough. Lungs clear to coarse bilaterally. Pt to nuclear med for V/Q scan. TF's at goal at 35cc/hr, no residual noted. Ostomy draining golden liquid stool, sample sent for c-diff. UO continues to be low, team aware, urine lytes sent. consulted this afternoon, Lantis dose lowered.\nPlan: Monitor resp status.\n Monitor crit\n Titrate Heparin gtt with sliding scale.\n Continue with .\n" }, { "category": "Nursing/other", "chartdate": "2158-07-19 00:00:00.000", "description": "Report", "row_id": 1608643, "text": "Respiratory Care Note\nPt received on PSV 15/5 - pt placed on SBT 5/0. Pt tolerated well with VT 386 RR 22. BS diminished throughout with improved aeration after MDI's. Pt suctioned for moderate amts thick, white secretions. Pt placed on trach mask. Pt tolerating well - will continue on trach mask as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-20 00:00:00.000", "description": "Report", "row_id": 1608644, "text": "NURSING NOTE\nHeparin at 1050units/hr\n" }, { "category": "Nursing/other", "chartdate": "2158-07-20 00:00:00.000", "description": "Report", "row_id": 1608645, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: ALERT & ORIENTED, MOUTHING WORDS, FOLLOWS COMMANDS CONSISTENTLY, MAES. C/O INTERMITTENT NECK PAIN, PO GIVEN. ATIVAN 1MG GIVEN FOR INSOMNIA W/LITTLE EFFECT.\n\nCVS: HR 70S, NSR W/FREQUENT PVC'S, SBP 90S-140S. AFEBRILE, HCT 27.3, MAG 1.8, K 4.2. PTT 61.1, INR 1.2, HEPARIN DRIP AT 10.5 UNITS/HR.\n\nRESP: TRACH COLLAR AT 50%, O2 SATS 99-100%. NARD, SUCTIONED/EXPECTORATED MOD AMT THICK, WHITE SECRETIONS. LUNGS COARSE, DIMINISHED AT BASES BILAT.\n\nGI/GU: NGT PATENT, AUDIBLE AIR ENTRY, MIN RESIDUALS, TF AT GOAL(35CC/HR). ILEOSTOMY PATENT, DRNG MOD AMTS BROWN, LOOSE STOOL. HRLY U/O>20CC.\n\nINTEG: COCCYX COVERED W/ALLAVERT DSG, C/D/I. PT TURNED FREQUENTLY FOR CHECKS, NO NEW AREAS BREAKDOWN NOTED.\n\nENDO: PT BS COVERED PER SS/STANDING DOSE\n\nPLAN: PULM TOILETING, HEMODYNAMIC MONITORING, HEPARIN DRIP/SERIAL PTT, PAIN MGMT, WND CARE, FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-28 00:00:00.000", "description": "Report", "row_id": 1608719, "text": "npn 0700-1900\n\nneuro: Pt is alert and is able to make her needs known by mouthing words. Follows commands and is able to MAE on the bed. No c/o pain or discomfort today. Slept all morning, but was awake and interactive when her family was here today.\n\nresp: PS 8/5 40%, which she is tolerating well. LS coarse. Suctioned for small amounts of thick white sputum infrequently.\n\ncv: Converted back into afib at 11 am. Missed amiodorone dose last night d/t access issues. PM dose given early because of increased HR. BP 140/70's.\n\naccess: L brachial PICC and HD line.\n\ngi/gu: Abdomen is soft with + BS. Will resume TF tonite. Ileostomy with pink stoma and very minimal amount of stool. patent foley with yellow, sedimented urine.\n\nendo: Monitoring BS q 4 h. receives NPH in am and Humalog sliding scale.\n\nCRRT: Last change at 1500. Goal fluid removal rate of 100 cc/h. Plan is to begin HD tomorrow as pt is hemodynamically stable.\n\nsocial: Dtr and husband in to visit this afternoon.\n\nplan: Continue to wean tommorrow- in am with goal of trach mask in afternoon. Next CRRT labs at 2200. When this clots please DC CRRTas HD will be initiated tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-28 00:00:00.000", "description": "Report", "row_id": 1608720, "text": "BS coarse crackles; no change with MDI's. PSV decreased to 8 without incident. Plan - continue to wean PSV; continue to remove fluid via CVVH.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-29 00:00:00.000", "description": "Report", "row_id": 1608721, "text": "Resp Care Note:\n\nPt trached and on mech vent and CAVH as Karevue. Lung sounds coarse suct sm th yellow sput. MDI given as per order. Pt in NARD on current settings; no vent changes required. PSV.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-29 00:00:00.000", "description": "Report", "row_id": 1608722, "text": "MICU NPN 7P-7A\nNEURO: RECEIVED PATIENT ALERT AND WATCHING TV. ABLE TO MAKE NEEDS KNOWN. MAE AND FOLLOWING COMMANDS. DENIES PAIN. SLEPT WELL, HALDOL HELD AS SHE WAS SLEEPY.\n\nCARDIAC: HR 99-110'S AFIB/ST WITH OCCASIONAL ECTOPY. BP 130-153/32-82. HCT STABLE @28. RECEIVED ON HEPARING GTT @500U/HR, NEXT PTT WAS 35 SO INCREASED TO 600U/HR. AM PTT WAS 40 SON NO CHANGES. NO SIGNS OF BLEEDING.\n\nRESP: ON CPAP 8/5 40% WITH RR 14-24, TV'S 300'S AND SATS 99-100%. LS CLEAR TO COARSE WITH DIMINISHED BASES. SXTED FOR THICK PALE YELLOW SPUTUM. RSBI 51, DECREASED PS TO 5 @0600.\n\nGI/GU: ABD SOFT WITH +BS. ILEOSTOMY INTACT WITH LIQUID STOOL. PEDITUBE IN PLACE. SCANT , YELLOW WITH SEDIMENT. CREAT 0.8 ON CVVHD.\n\nFEN: ON CVVHD AND TOLERATING NET GOAL OF -100CC/HR. WAS -1.5L @MIDNOC AND IS NOW -4L LOS. CA++ AND KCL GTTS INFUSING AND ADJUSTED TO SLIDING SCALES. NO CHANGE IN CVVHD SOLUTIONS. LYTES PER CAREVUE. FS 156-325 WITH SS HUMMALOG AND NPH DUE THIS MORNING. TUBE FEEDS @40CC/HR AND TOLERATED WELL.\n\nID: TMAX 98.7 WITH WBC 9 DOWN FROM 15. CONTINUES ON CEFTAZ FOR PREVIOUS INFILTRATE SEEN ON CXR AND FINISHING COURSE OF 10DAYS FOR POSSIBLE ASPIRATION WHEN HER NGT WAS PULLED OUT AND SHE HAD A RISE IN HER WBC. ON CONTACT PRECAUTIONS.\n\n: DUODERM TO COCCYX.\n\nACCESS: RSC DIALYSIS CATH, LEFT BRACHIAL PICC.\n\nSOCIAL/DISPO: FULL CODE. HUSBAND HAS CALLED TWICE FOR UPDATES, STATES HE WILL BE IN THIS AFTERNOON.\n\nPLAN IS TO REMOVE CVVHD AND GIVE HER A TRIAL OF HD WITH HER IMPROVED BP. ALSO WEANING VENT SUPPORT IN HOPES OF GETTING HER TO TRACH MASK TRIAL. NEXT CVVHD/PTT DUE @1030.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-26 00:00:00.000", "description": "Report", "row_id": 1608620, "text": "NPN 1900-0700\nEvents: L SC TLC line changed over wire to Quinton cath in prep for dialysis in AM.\n\nNeuro: Pt. sleeping all night but aroused and alert and oriented. Cooperative with care. MAE. ? Uremia contributing to Pt.'s current MS.\n\nCV: VSS. BP remains elevated raging 130's-160's/60's-70's. HR 50's-70's NSR with occ. PVCs. Generalized pitting edema. Weak pedal pulses to R lower ext. Pt. on multiple antihypertensive meds. ? HTN related to fluid overload.\n\nResp: Pt. placed on mask ventilation for line change to help her tolerate lying flat. Pt. back on 3L NC after procedure and resp. status remains stable. LS clear and dim at bases. Occ non productive cough noted. O2 sat 98-100%. No resp. distress noted at this time.\n\nGI: Abd. obese with illeostomy to R upper abd. draining soft brown stool. BS+. Taking PO meds without difficulties. Pt. remains on Insulin gtt with FS q2 hr due to sore fingers. Insulin gtt off during line change but restarted after CXR was taken and read.\n\nGU: Urine output remains low ~10cc/hr. Bloody urine noted in foley tubing at begining of this shift. MD made aware. Foley flushed and urine now yellow with small amount of bloody sediment.? floey cath pulled and caused trauma. Dialysis today. Fluid status +1.4L for LOS.\n\nID: Remains afebrile. blood cx. pending. Urine cx. + for yeast. Sputum cx. gram+ cocci. Pt. restarted on IV Flucanazole, Vanco dosed per level, and cefepime.\n\n; Large bruise to lower abd from heparin injections in the past. L BKA iktact. SCD to R leg in place. Pt. did not like to be repositioned frequently, preffered lying on her back. C/O L shoulder pain, ? post line change irritation. medicated with PO Tylenol with good effect.\n\nSocial: Pt.'s husband in to visit last evening. Updated on plan of care. Pt. is a full code.\n\nPlan: Dialysis in AM. Monitor FS and maintain Insulin gtt as ordered. Monitor labs.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-26 00:00:00.000", "description": "Report", "row_id": 1608621, "text": "Addendum 1900-0700\nCV; AM Hct. 20.6. type and screen sent. Need transfusion consent. House staff will call husband at 0700 to get consent for transfusion.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-26 00:00:00.000", "description": "Report", "row_id": 1608622, "text": "RESPIRATORY CARE NOTE\n\nPatient remains with 6.0 sleep apnea tube capped. During dialysis catheter placement, patient was placed on NIPPV and tolerated well. Taken off and placed back on 3 lpm nasal cannula.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2158-07-24 00:00:00.000", "description": "Report", "row_id": 1608663, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: LETHARGIC THIS AM, MORE INTERACTIVE AS DAY HAS PROGRESSED, MOUTHING WORDS FREQUENTLY\nCV: T MAX 101.6 THIS AM, TYLENOL GIVEN (NOT CULTURED), PRESENTLY AFEBRILE, HR 60-80'S NSR WITH RARE PVC. SBP 115-130'S.\nRESP: WEANED TO CPAP WITH 5 IPS AND 5 PEEP. BS COARSE. SX FOR THIN WHITE SECRETIONS.\nGI: TF OFF FOR SEVERAL HOURS SECONDARY TO HIGH RESIDUAL. RESUMED AT 1600. ABD SOFT. ILEOSTOMY PATENT WITH LARGE AMT LOOSE BROWN STOOL\nGU: CLOUDY YELLOW URINE IN ADEQUATE AMTS. LASIX 40MG IV X 1 AFTER 250CC NS BOLUS FOR HIGH CALCIUM\nENDO: INSULIN GTT RESTARTED THIS AM FOR BS 286. TITRATED AS HIGH AS 8 UNITS (BS 340). BY 1500 BS 90'S- INSULIN GTT HALVED AND REPEAT BS 54. INSULIN GTT OFF AND TF RESTARTED AT THIS TIME. BS PENDING.\nA: HEMODYNAMICS AND RESP PARAMETERS MONITORED, SX PRN, BS Q1HR\nR: TOL VENT WEAN, HEMODYNAMICALLY STABLE, TO MONITOR BS CLOSELY, CHECK TF RESIDUAL Q4HRS.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-07-24 00:00:00.000", "description": "Report", "row_id": 1608664, "text": "condition update\nD: pt placed on trach collar at 1700, fio2 50%. resp rate 18-24. sats >97%, pt appears comfortable.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-25 00:00:00.000", "description": "Report", "row_id": 1608665, "text": "Respiratory Care Note:\n patient remained off vent this shift and on a trach collar with cool mist at 50%. SX for small amounts of white thick secretions. Patient has a good cough effort raising secretions as well. BS are clear. MDI's administered as ordered with good effect. RR remained 17-22, SPO2 99-100%. patient remained afebrile this shift. Plan is to maintain trach collar as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-25 00:00:00.000", "description": "Report", "row_id": 1608666, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt alert, mouthing words, follows all commands, MAE, denies pain. Slept intermittently throughout night.\n\n Resp: LS Clear to coarse throughout bilat. Remained on trach collar throughout shift, tol well. Suctioned prn for small amounts of thick white secretions. Denies SOB. Trach care performed.\n\n CV: Remains in NSR, occational PVC's noted. Hct stable. +2 Edema noted. Denies CP. VSS.\n\n GI: Abd soft, n-t, pos bs noted. Tol tubefeeds well through night until am. c/o nausea, vomited 25cc of tubefeed, residual 120cc, tubefeeds held and MD notified. Nausea has since resolved. Ileostomy with mod amount of brown liquid stool. Colace held due to lg amounts of stool output on previous shift.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n Endo: Sugars labile. Recieved 12units lantus at 2200, insulin gtt now off and covering sugars with s/s insulin.\n\n Plan: Keep pt on trach collar for as long as pt can tol, glucose control, monitor tubefeed residuals, ? transfer to floor, provide pt and family qith emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-02 00:00:00.000", "description": "Report", "row_id": 1608735, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 6.0 Portex DIC trach tube. On 40% TM and tolerating well at this time. Administering albuterol and atrovent with spacer through trach tube. BLBS are diminished.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608689, "text": "micu npn 1900-0700\npt received a sl ntg w/much improvement in pain, pt sleeping presently. at 0530, pt c/o chest tightness to mid sternum, indicitating that this is similar to the pain of her mi xyrs ago. ecg done w/o changes per dr . ck/enzymes to be cycled. pt received 1 mg morphine iv w/some effect. pt now c/o l neck pain as well as l back/shoulder. dr aware, debating whether to give her morte morphine at this point.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608690, "text": "Resp. Care\nPt. remains on mech vent CPAP/PS and 40%.B/S were scat rhonchi and was sx for mod amts thick yellowsecr. MDIs given and tol well with good effect and better aeration post rx.Pt. received dialysis thru night. Plan is to wean back to trach collar.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608691, "text": "FOCUS; NURSING PROGRESS NOTE FOR ALTERED RENAL FUNCT\nRENAL- PATIENT REMAINS ON CVVHD. THIS AM UNABLE TO TAKE OFF ANY FLUID DUE TO HYPOTENSION. AS DAY PROGRESSED SBP INCREASED FROM 70-80'S UP TO THE 100'S. ABLE TO RUN PATIENT EVEN AND HAD AND A STABLE BP. INCREASED TO NEG 50CC/HR. SHE HAS BEEN TOLERATING THIS AND WILL AS LONG AS HER BP WILL TOLERATE IT. RENAL FELLOW DR UP IN THE AFTERNOON AND WAS UPDATED AS TO HOW WE ARE DOING ON THE CVVHD. SHE WISHES TO CHANGE THE TRISODIUM REPLACEMENT FLUID TO PRISMASATE. WILL HANG BAG WHEN AVAILABLE FROM PHARMACY. ONCE THIS FILTER CLOTS SHE WILL RECEIVE HEPARIN THROUGH HER CVVHD. ORDERS WRITTEN FOR THIS. CA DRIP HAS BEEN LIBERALIZED 4PM LABS DRAWN AND SENT SO WILL ADJUST PER RESULT. ON BAIRHUGGER PRN FOR TEMP IN THE 97. RANGE. TEMP NOW UP TO 99.2. BAIR HUGGER OFF. NEXT SET OF CVVHD LABS WILL BE DUE AT 2200.\nPLAN- TO TAKE OFF 50CC AN HOUR AS HER BP TOLERATES.\n ONCE THIS SYSTEM CLOTS START HEPARIN VIA HER NEXT SYSTEM.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608692, "text": "Nursing NOte 0700-1900\nPt. admitting dx. Dyspnea, increased renal failure, volume overload and fungemia related to TPN, became lethargic and disoriented, sbp dropped to the 70's, desat to the 70'sand question of sepsis.\n\nPMH ischemic bowel disease,ileostomy, respiratory failure, s/p tracheostomy, echo EF 25-30%, dilated LA, LVH, mod MR, mod TR, hyponatremia, s/p renal transplant 92, CRF, ATN, L BKA, MIx2, CABGx2, L eye prostesis,gout, bilat breast cancer, xrt and chemo.\n\nPt. was stable throughout day, no further complaints of pain, occaisional PVC'S noted. Cardiology consult ordered.\n\nNEURO: Pt. A and O x2, not oriented to place. responds appropriately to commands and stimuli. PERRLA 2+, hand grasps equal. Mae.\n\nRESP: CPAP PS 10/5 fio2 40%; Tv 400 or greater. LS course R and L upper and diminished in the lower blat. Pt. suctioned for thick white sputum exibiting small amount of anxiety during procedure. Trach care done site CDI.\n\nCV: HR 91-110, SBP 76-118, NSR noted with occaisoinal PVC'S. Cardiology consult ordered and continuation CVVHD to try for negative today. Ck being cycled. 21 and 36. troponins 0.07-0.15. Seen by cardiology today who feel increased troponins are due to hypotension and demand in patient who is anemic. agree with cvvhd to help with fluid removal.\n\nACCESS: L PICC double lumen patent CDI, R quintin catheter for dialysis DSG changed CDI.\n\nGI/GU: Foley draining yellow urine with sedament 55cc total. Ileostomy draining brown loose stool, guiac positive HCT 26.3. Doboff feeding tube placed at 0100, stat x-ray pending. Tf of novasouce pulmonary ordered once doboff tube placement confirmed. fk506 level low at 3.9. evening dose as well as am dose of tacrolimus ordered by renal fellow.\n\n: Duoderm to coccx intact, warm dry intact.\n\nID: PT. remained afebrile. on day of fluconazole. on ceftazadime. on vanco by level. Vanco level this am 26.1. No dose given.\n\nENDO: Blood glucose at 0800 208 4 units humalog and 2 NPH per dr . Blood sugar at 1200 133 2 units humalog given per sliding scale. Blood sugar at 1700 51 ampule 50% dextrose given. F/U B.S. 101 at 1800.\n\nSOCIAL: Pt. husband visited today and updated on pt. status.\n\nPLAN: Continue with CVVHD negative goal for the day. Start tube feed after confirmation of placement.Continue to monitor labs. Next cvvhd labs due at 2200. next ck due at .\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608693, "text": "Resp Care\nPt remains on PSV, no vent changes. Pt recieving dialysis, plan to wean to TM when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-24 00:00:00.000", "description": "Report", "row_id": 1608694, "text": "RESP CARE: Pt remains trached with 6.0 Portex trach tube/on vent on PSV all shift. Cuff pressure 30cmH20. Vts on 10 PS 440-500/RR 15-30. Pv02 WNL. Lungs coarse bilat. Sxd small amts thick yellow/white sputum.MDIs given with good effect noted. RSBI this am on 0 PEEP/5 PS was 54. Plan is for pt to return to trach collar once CVVHD is complete.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-24 00:00:00.000", "description": "Report", "row_id": 1608695, "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 55 Y/O F PT WITH MULTIPLE MEDICAL PROBLEMS INCLUDING HTN, DM, PVD, S/P RENAL TRANSPLANT WITH CRF, INFARCTION OF COLON, S/P COLECTOMY AND ILEOSTOMY IN WHO WAS TX TO FROM OSH ON SECONDARY TO SOB, ARF VOLUME OVERLOAD, FUNGEMIA, THROMBOCYTOPENIA AS WELL AS A CENTRAL LINE INFECTION. PMH SIGNIFICANT FOR GOUT, ANEMIA, BILATERAL BREAST CA S/P LUMPECTOMY, S/P XRT/CHEMO, MESENTERIC ISCHEMIA WITH COLECTOMY IN , RESPIRATORY FAILURE S/P TRACH , CRF S/P RENAL TX , PVD S/P L BKA, MI X2 S/P CABG X 2. PT HAS HAD MULTIPLE ICU ADMISSIONS BETWEEN THE MICU WEST BUT HAD BEEN DC'D TO THE FLOOR WHERE SHE HAD BEEN DOING FINE UNTIL WHEN SHE DEVELOPED ALTERED MENTAL STATUS IN COMBINATION WITH HYPOTENSION AND TACHYCARDIA- READMITTED TO MICU 7. CVVHD INITIATED WITH GOAL OF REMOVING FLUID AND WEANING PT FROM VENTILATOR WITHIN THE NEXT 48-72 HOURS.\n\nNEURO: PT IS ALERT AND ORIENTED X 2. ABLE TO FOLLOW COMMANDS WITHOUT DIFFICULTY AND IS ABLE TO MOUTH WORDS TO EXPRESS NEEDS. PT HAD DISCUSSION WITH THIS RN ABOUT HOW SHE WANTED TO GET BETTER AFTER HAVING HAD A HOSPITAL STAY FOR 4 MONTHS. PT EXPRESSES SOME FRUSTRATION BUT REMAINS HOPEFUL. ABLE TO MAE X 3. ASSISTS WITH TURNING AND PERSONAL CARE. PT HAS GLASS LEFT EYE. RT PUPIL IS 3/BRISK REACTION TO LIGHT. PT HAS HAD INTERMITTENT NEED FOR BAIR HUGGER- TEMPS HAVE BEEN IN THE 97 RANGE. NO SEIZURE ACTIVITY NOTED. PT 1MG OF HALDOL TO HELP WITH SLEEP- DISCUSSED WITH DR. POSSIBILITY OF STARTING PT ON PRN AS PT HAS HAD C/O NOT BEING ABLE TO SLEEP WELL.\n\nRR: TRACHED. TRACH IS MIDLINE AND SECURE. PT TOLERATED TRACH CARE. BBS= ESSENTIALLY COARSE TO BILATERAL UPPER LOBES AND DIMINISHED TO THE BASES. BILATERAL CHEST EXPANSION NOTED. SUCTIONING FOR THIN, WHITE SECRETIONS IN SMALL TO MODERATE AMOUNTS. CURRENT VENT SETTINGS ARE 5/10/40% CPAP/PS. PT DID NOT TOLERATE SBT THIS AM. VBG'S WNL. SP02 > OR = TO 95%. RR 20-25. PT HAS HAD NO C/O SOB OR DIFFICULTY BREATHING. STRONG COUGH EFFORT.\n\nCV: S1 AND S2 AS PER AUSCULATION. NSR-ST, HR 90-100'S WITH RARE PVC'S NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. INITIATED HEPARIN GTT AT 2400 WITH NEW CVVHD FILTER INITITATION. CURRENTLY AT 400U/HR. NO OBIVOUS SIGNS OF BLEEDING NOTED. PT HAS HAD REPEATED LOW ION CA- CURRENTLY ON CAGLUC GTT AND RECEIVED TOTAL OF ADDITIONAL 6GMS OF CA GLUC. WILL CONTINUE TO MONITOR. PT IS ALSO CURRENTLY ON POTASSIUM GTT WITH SLIDING SCALE- RECEIVED ADDITIONAL 40MEQ IV FOR REPEATED LOW LEVELS GIVEN PT'S CARDIAC HISTORY. PT HAS NOT HAD ANY C/O CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL RADIALS. PT HAS PICC LINE TO LT UPPER ARM.\n\nGI: ABD IS SOFT, DISTENDED AND NON-TENDER TO PALPATION. PT HAS STOMA IS RED- BROWN, SOFT, LIQUID STOOL NOTED. DOBHOFF INSERTION- PROPER PLCMT VERIFIED WITH\n" }, { "category": "Nursing/other", "chartdate": "2158-08-24 00:00:00.000", "description": "Report", "row_id": 1608696, "text": "NURSING PROGRESS NOTE 1900-0700\n(Continued)\nXRAY- PULMONARY NOVASOURCE INITIATED WITH GOAL RATE OF 40CC/HR- CURRENTLY AT 30CC/HR AND TOLERATING WELL. NO C/O N/V.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. PT ANURIC. WHAT LITTLE URINE SHE MAKES IS YELLOW AND CLEAR. ONGOING CVVHD AT BEDSIDE- NO PROBLEMS- LAST CHANGE AT 2400. CURRENT GOAL IS -50CC/HR. TOLERATING WELL.\n\nINTEG: DUODERM IS INTACT AND PATENT TO COCCYX. NO OTHER SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. PT NOTED TO HAVE PITTING, GENERALIZED EDEMA.\n\nSOCIAL: VERY INVOLVED HUSBAND- UPDATED ON PHONE BY THIS RN.\n\nPLAN: CONTINUE TO MONITOR ELECTROLYTES- NEXT SET OF CVVHD LABS IS DUE AT 0800. TREAT CA PRN. GOAL IS FOR -50CC/HR. CONTINUE EMOTIONAL SUPPORT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-09-02 00:00:00.000", "description": "Report", "row_id": 1608736, "text": "1900-0700 rn notes micu\n\nneuro: no changes in neuro status,pt alert,communicate with mouth words and nod head fro yes/no, pt's PMV off.\n\nresp:on trach collar mask 40%, sat 98-100%, Ls clear/dim at bases,suction for moderate amount white secretion.pt has good cough.\n\ncv: HR 80's, NSR wirh rare PVC's. NBP 120-150's/50's, cardiac meds PO. Heparin, at 2200 PTT 141, Heparin decraesed to 400u/hr. morning labs pending.\n\ngi/gu: foley passing cloudy urine ~10-15cc/hr. ABD soft, BS+, passing loose stool via ileostomy.\n\nendo: at 2200 BSFS 53, given 1/2amp D50% and 10u NPH MD. after hour BSFS 91.\n\nid: afebrile, ABX.\n\nsocial: full code, husband called/updated.\n\nplan: follow resp/cardio status\n follow BSFS\n" }, { "category": "Nursing/other", "chartdate": "2158-09-02 00:00:00.000", "description": "Report", "row_id": 1608737, "text": "Respiratory Care: Pt remains trached on trach collar, 40% cool aerosol. Pt's sounds diminished bilaterally. Pt sx for small thick yellow secretions. Pt with PMV on afternoon as per nurse's request, cuff down, pt tolerating well. MDI's given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2158-09-02 00:00:00.000", "description": "Report", "row_id": 1608738, "text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-vs have been stable. receiving all po cardiac meds. no c/o chest pain, palps. no afib noted.\n\nRESP-has been on 40% trach collar all day,with good sats >95%. has had PMV in place for several hours. has a strong cough productive of thickk sputum, has also been sx several times for thick yellow sputum.lungs are clear, diminished at bases.utilizing aspiration precautions with all meals.VBG this am with somnulence- po2 52, pco2 44 and pH 7.38.\n\nID-afebrile. is off antibx.urine cx sent as there is alot of sediment.\n\nNEURO-was bright and alert this am, then somnulent on rounds and difficult to arouse, did move extremities and open eyes to stimulation and nodded weakly.neuro exam otherwise nl. she did wake up shortly thereafter and is quite alert and oriented.eating well with minimal assistance.\n\nGI-as above, eating well.is on protonix po.passing large amt of brown liquid stool via colostomy. fresh bag applied.\n\nF/E- urine has been cloudy yellow with sediment, ~ u/o ~20-30 ccs/hr.still with some peripheral edema.please see labs in carevue.was repleted with 4 gms mag sulfate and 2 pkts neutrophos.\n\nHEME-heparin drip infusing at 750u/hr- PTT =103, no change in drip made.\n\nENDO-have been checking freq fingersticks, receiving regular insulin as per sliding scale, NPH.\n\nIV ACCESS-has a double lumen PICC and a dialysis catheter\n\nSOCIAL-husband called several times and visited, needs alot of info.\n\na-uneventful day\n\nP-will have next dialysis probably on monday as per renal team.will continue with good pulm toilet.she said this evening she would like to get up to the chair tommorrow.pt is called out to the floor and transfer note started.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-30 00:00:00.000", "description": "Report", "row_id": 1608635, "text": "RESP: BS'S DIM. ON LEFT. BUT O2 SATS REMAIN IN 90'S. USING INCENTIVE SPIROMETER. COUGH NONPRODUCTIVE.\nNEURO: UNABLE TO SLEEP LAST NIGHT-VERY CRANKY TODAY. NERVOUS ABOUT NOT SLEEPING TONIGHT. AMBIEN ORDERED FOR LATER THIS EVENING. PT IS SLEEPING AT THIS TIME. GIVEN ATIVAN PO FOR ANXIETY.\nGI: APPETITE INCONSISTENT TODAY. PT. IS ALLOWED BY AND HO TO REGULATE HER OWN BS'S. BETTER CONTROL TODAY.\nRENAL: AUTODIURESING. CREAT 1.8. PLAN IS FOR POSSIBLE HD ON MONDAY TO PULL MORE FLUID OFF. STILL EDEMATOUS.\nCV: HEMODYNAMICALLY STABLE. INCREASED ECT (PVC'S) D/T LOW K+ AND MG+.\nENDOC: K+ AND MG+ REPLETED.\nID: . ON ANTIBIOTICS. AFEBRILE. WBC'S DROPPING.\nACCESS: QUINTON CATH INTACT. DRSG D&I. NO REDNESS.\n INTEGRITY: DUODERM CHANGED ON BUTTUCKS.\nACTIVITY: PT. REFUSING TO GET OOB. VERY ANXIOUS ON LIFT.\nPLAN: TRANSFER TO F10 WHEN BED AVAILABLE. TRANSFER NOTE DONE ON .\n" }, { "category": "Nursing/other", "chartdate": "2158-07-01 00:00:00.000", "description": "Report", "row_id": 1608636, "text": "MICU Nursing Progress Note\n Pt received 0.5 ativan and then two hours later amiben 5mg fell asleep most of the night. Pt is using her home method of treating her sugars... after dinner she calculated her carb intake and received 4units of humalog...at . at 2300 she recieved 26units of glargine.. Fs 146 no humalog given. however pt woke up at 4am c/o feeling her sugars were too low... was 64 given two apple juices and recheck was 67... two more apple juices and crackers.\n will keep close monitor on sugars.\n Plan: transfer to medical floor when available.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-25 00:00:00.000", "description": "Report", "row_id": 1608618, "text": "NPN 1900-0700\nNeuro: Pt. sleeping most of the shift, even when family present. aroused, alert and oriented. Following commands. L eye prosthesis in place.\n\nCV: Extensive cardiac hx. VSS. BP 140's-160's/70's-80's. HR 70's-100's A-fib with occ PVCs. Pt. on multiple cardiac meds. Generalized edema/ fluid overload. AM labs pending.\n\nResp: RR easy ~13-20 breaths/min. LS clear and dim at bases. O2 sat 98-100% on 3L NC. No cough. Old trach site caped.\n\nGI: Tolerating diet well with poor PO intake. Pt. on insulin gtt currently on 2units/hr with BS 140's-180's. Illeostomy to R abd. with small amount of brown loose stool. Abd. obese, BS+. Large bruise noted to low abd. Pt. states it is from SC Heparin and Lovenox.\n\nGU: ARF with creat 3.7 on AM. Pt. s/p renal translant in '. Renal team following Pt. probable dialysis soon. Foley cath in place draining ~10-15cc/2 hr. ICU team aware. No diuresis after Lasix which was given by day shift on . Free water restriction rec per renal team for low Na. Fluid status even since midnight and +1.2L for LOS.\n\nID: afebrile. WBC 19.4 on . Pt. on Vanco and cefipime. Flucanazole was d/c'ed. Vanco dosed per level due to RF. It. is belived that LSC TLC is a source of fungemia and the plan is to resite if possible of change over , possibly in AM. Need of cx cath tip. MRSA in blood.\n\nAccess: LSC TLC all ports patent. Pt. has req. for PICC placement in IR ? when. Pt. will also need line if she needs dialysis. Poor peripheral access.\n\nSocial: Pt.'s husband and daughter in last evening to visit. All aware of plan of care. pt.is a full code.\n\nPlan: Possible dialysis afeter access established. Needs PICC and LSC line d/c'ed and tip cx. COnt. on Insulin gtt and if Pt. hypoglacymic give Dextrose and do not stop Insulin gtt.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-25 00:00:00.000", "description": "Report", "row_id": 1608619, "text": "Micu nsg progress note\n Pt very lethargic sleeping on and off all day. Easily and able to follow commands without difficulty.\nCardiac- Cont hypertensive despite hydralizine/metoprolol/isordil/\nclonidine. Now in nsr with occasional pvc's hr 60's-70's. Cont with 3+ pitting edema all extremitties. Urine output remains poor. No further lasix. Plan for dialysis tommorrow.\nResp- C/o intermittent difficulty clearing secretions. Productive cough sm amts thick bloody secretions. Ho aware. Sats remain stable on 3l nc 99%. Pt tried on cpap mask in attempt to allow pt to lay flat for line placement. Appears to tolerate. Plan to place dialysis line over wire later today.\nGi- Taking po's but appetite poor. Cont on insulin gtt with fs 89-126 on 1-2u insulin.\nId- Remains afebrile. Restarted on fluconazole. Cont on vancomycin (dosed according to level) and cefepine.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-22 00:00:00.000", "description": "Report", "row_id": 1608682, "text": "Nursing Progress Note 1900-0700\n\n55 year old female with a complex medical history which includes HTN, DM CAD s/p MI & CABG x 2 with EF 25%, PVD s/p L BKA, mesnteric ischemia s/p colectomy with ileostomy, ESRD s/p XPL , bil breast CA s/p lumpectomy/XRT/Chemo, Resp failure s/p trach. She was transferred to the MICU this afternoon after an episode of hypotension & mental status change. A Chest X-ray & Echo today showed moderate-severe bilateral pleural effusions. B/C + for fungemia, she is currently on day of fluconazole IV.\n\nNeuro: Alert & oriented x 3. Moving all 4 extremities spontaneously, following commands. Pt very anxious at beginning of shift r/t labored breathing and fear of dying. 1 mg IV Haldol given with fair effect.\n\nResp: Trached, communicating with PMV. RR at beginning of shift 22-30, sats 100% on 50% trach mask. Pt with complaints of feeling SOB. At 2230, pt placed on ventilator. Settings P/S 40%. RR 15-20, with TV 500-590. Venous Gas 7.31/35/45. Since initiation of PS, pt w/o complaints of SOB. Sleeping comfortable rest of shift. Suctioned Q-3-4 hours for small amounts thick yellow secretions. Lung sounds coarse throughout.\n\nCV: Tele SR-ST with frequent PVC's. BP 90-100/50-60's with MAPS in high 50's to 60's. +2 pt/dp on right. Left BKA. trace edema in upper extremities.\n\nGI: + BS in 4 quadrents. Ileostomy site beefy red. Small amount of loose brown stool noted in collection bag. Tolerating small amounts of soft solids. Needs assistance with eating.\n\nGU: Foley draining very small amounts of cloudy/sediment urine. THis AM BUN 26 Creat 2.6, K 4.6. Being followed by renal. HD PRN as clinically indicated.\n\nID: T-max 98.5 oral. Blood cultures drawn. U/A sent. Started on Ceftazidime. Day of fluconazole for fungemia. WBC 6.9. Random Vanco level pending.\n\nHeme: HCT 26.6 this am down from 28.5\n\n: Duoderm on coccyx intact. No other areas of breakdown noted\n\nEndo & Electrolytes: FS 119 at 22, 03 77. Pt with hypercalcemia over the past few days. AM calcium 10.5\n\nSocial: Husband called x 2, MD called husband and discussed and need for ventilator support.\n\n\nPlan:\n\n1. ? Tap of pleural effusions\n2. Monitior Respiratory Status, follow ABG's.\n3. Routine ICU care\n4. Emotional support to patient and family\n" }, { "category": "Nursing/other", "chartdate": "2158-08-22 00:00:00.000", "description": "Report", "row_id": 1608683, "text": "Resp. Care\nPt. was on trach collar till 2300 when she c/o sob and became tachypnic and tachycardic.Pt was ordered on CPAP 10/5 and 40% in order to put her at ease for the night and to resume trach collar in A.M.after rounds. Abgs were refused by the pt after attempts by MD. SOUNDS ARE scat rhonchi and she was sx for sm amts thick yellow thru her 8.0 portex with a cuff inflated to 30 cc\n" }, { "category": "Nursing/other", "chartdate": "2158-08-22 00:00:00.000", "description": "Report", "row_id": 1608684, "text": "FOCUS; NURSING PROGRESS NOTE\n55 YEAR OLD FEMALE WITH PMH TYPE 1 DM,CAD, PVD S/P LEFT BKA, ESRD S/P RENAL TRANSPLANE. ADMITTED TO THE HOPSITAL IN WITH ISHCEMIC COLITIS. UNDERWENT A COLECTOMY AND ILEOSTOMY. POST OP COURSE COMPLICATED BY RESP FAILURE. SHE WAS TRACHED AND WENT TO REHAB. RETURNED FROM RHEAB WITH A FUNGEMIA. MULT TRIPS FROM FLOOR TO ICU AND BACK AGIAN FOR RESP FAILURE AND SEPSIS. HAS HAD A RECURRENT FUNGEMIA OF UNKNOWN SOURCE. FINISHED CASPOFUNGIN ON . PRESENTLY ON DAY FLUCONAZOLE. SHE WAS ADMITTED TO THE MICU YESTERDAY AFTER BEING HYPOTENSIVE ON THE FLOOR AND HAVING DIFFICUTLY BREATHING. TX WITH 1.5 L IVF. LAST EVENING PLACED ON THE VENT. OF NOTE EF HAS DECREASED FROM 50% TO 20% WITH GLOBAL HYPOKENESIS.\nREVEIW OF SYSTEMS-\nNEURO- SHE IS ALERT AND ABLE TO COMMUNICATE BY MOUTHING WORDS OR WRITING. MAE. OF NOTE SHE HAS A GLASS LEFT EYE.\nRESP- SHE IS TRACHED AND VENTED. ON 40% FIO2/ PEEP 5/ PS OF 10 TV ARE AROUND 500 WITH RESP RATE 15-23. BS COARSE. DIMINISHED AT THE BASES. SHE HAS REQUIRED SUCTIONING AND LAVAGE APPROXIAMTELY Q 4 HOURS FOR THICK YELLOW SECRETIONS THAT CAN NOT ALWAYS COME UP WITHOUT LAVAGE. RECEIVING INHALERS PER RESP.\nCARIDAC- HR 80-100 AT REST. WITH TURNING AND NEED FOR SUCTIONING HAS BUMPED TO 150. COMES DOWN TO BASELINE AFTER SUCTIONING AND A FEW MINUTES OF REST. SBP 100 OR GREATER TODAY. IONIZED CA PRIOR TO STARTING CVVHD WAS 1.5. DR RENAL FELLOW WAS INFORMED. CA DRIP FOR CVVHD OFF AT PRESENT. RECEIVING 30GMS OF PAMIDRANATE OVER 4 HOURS. IF IONIZED CA 1.3 OR GREATER RENAL FELLOW WOULD LIKE TO BE INFORMED WHEN CVVHD LABS DRAWN. IF LOWER CA DRIP CAN BE STARTED PER SS WHICH HAS BEEN DECREASED FROM THE NORMAL REPLACEMENT SS ON CVVHD. K 4.6. ON 10MEQ IN 100CC AT 20CC/HR AS INITIAL RATE FOR K DRIP WITH CVVHD. ON STRESS DOSE STEROIDS.\nGI- ABD SOFT DISTENDED WITH POS BS. SEEN BY SPEECHA ND SWOLLOW WHO SAY SHE TAKE PILLS ON THE VENT BUT SHE SHOULD NOT EAT. THEY WILL REASSESS HER TOMMORROW. ILEOSTOMY WITH BROWN LOOSE GUIAC POS STOOL. APPLIANCE CHANGED YESTERDAY PER REPORT. STOMA RED AND WARM TO THE TOUCH.\nGU- FOLEY PATENT WITH MIN YELLOW URIEN WITH SLUDGE.\nRENAL- STARTED CVVHD THIS AFTERNOON AT 1600. GOAL IS FOR -50 CC/HR. SHE WAS RUN EVEN THE FIRST HOUR AND TOLERATED IT WELL. ACCESS PRESURES WITH EXTREMELY NEG SO LINES WERE SWITCHED AND ACCESS PRESSURE MUCH IMPROVED. SEE ORDERS FOR CVVHD ORDERS . RIGHT SC QUINTON BEING USED.\nID- TEMP MAX 98.8. RECEIVED 1 X DOSE OF VANCO FOR LEVEL 15.6 THIS AM. ON FLUCONAZOLE DAY TODAY. RECEIVING CEFTAZADIME AS WELL.\nENDO- BS 90-105 RANGE TODAY . ON SS HUMOLOGUE. ENDOCRINE BY. SHE IS TO GET 5 U NPH AT BEDTIME INSTEAD OF 7 UNITS SHE WOULD GET IF SHE WERE EATING. ORDERS WRITEN FOR THIS.\n HUSBAND IN AND UPDATED BY THIS NURSE ON PLAN OF CARE.\nDISPO- REMAINS IN THE MICU A FULL CODE.\nPLAN- ANTIBIODICS AS ORDERED.\n CVVHD WITH GOAL OF NET NEG 50CC Q HOUR.\n VENT SUPPORT TONIGHT. / WEAN TO OFF IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-18 00:00:00.000", "description": "Report", "row_id": 1608637, "text": "Resp Care\nPt. received from floors in Resp. Distress RR>40 with retractions, abdominal breathing. Currently has #6 Sleep Apnea tube. Changed to # 6 Portex Cuffed in order to ventilate pt. Trach changed w/o incident or trauma noted. + CO2 change, breath sound bilat.\nSxn'd for thick white x1. Placed on PSV with noted decreased WOB. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-18 00:00:00.000", "description": "Report", "row_id": 1608638, "text": "BS coarse crackles and diminished. Started on MDI's prn with increased aeration. FiO2 weaned; no other changes. Will continue to wean to prior status once current pathology is identified.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-18 00:00:00.000", "description": "Report", "row_id": 1608639, "text": "Nursing Update\nSee flowsheet for specific info.\n\nPt here from floor in resp distress.\n\nNeuro: Pt arrived alert and oriented, following most commands, and MAE's. 2mg Ativan given for anxiety. Sleeping most of day, arouse to voice.\nCV: NSR, brady at times, sbp 120-160. Afebrile. Pt has dialysis cath, and is difficult to start a line on, OK to use cath for meds, etc per dialysis. Extra port clotted off, will Tpa to try to clear. LENI's done this afternoon.\nResp: Trach placed upon arrival to unit, pt tolerated well, placed on CPAP , sating 98-100%. Lungs clear to coarse bilaterally. V/Q scan ordered, then canceled by MICU.\nGI: Abdomen soft, BS+. Colostomy draining brown loose stool.\nGU: Foley to gravity, UO low d/t dialysis.\nPlan: Monitor resp status.\n Possibly back to floor tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-19 00:00:00.000", "description": "Report", "row_id": 1608640, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 6.0 Portex DIC trach tube. Ventilated on PS settings all noc. Tolerated well. Sxn for thick white secretions, moderate amount. RSBI completed on PS 5=86.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 1608715, "text": "npn 0700-1900\n\nNo changes today.\n\nneuro: Pt is alert. She is able to mouthe words and make her needs known. Follows commands. No complaints of pain or discomfort.\n\nresp: Remains on PS 10/5 40%. Secretions have increased over the course of the day-- requires suctioning 4-5 times per hour for thick, yellow sputum. Dr. made aware. Will send sputum culture.\n\ncv: SR-ST 90-115 with occasional pvc's. BP 130-140/70-80's.\n\naccess: L brachial PICC ans RSC dialysis line.\n\ngi/gu: Belly is soft with + BS. TF at goal via dobhoff. Patent foley at 5-10 cc/h.\n\n: Duoderm intact on coccyx, othewise intact.\n\nendo: recs am NPH dose increased. BS at 1600 was 133.\n\nCVVH: Continues with goal removal rate of 100cc/h. Tolerating well.\nGoal for today is for pt to be 1 liter negative.\n changed at 1700.\n\nplan: Send sputum. Wean vent tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-22 00:00:00.000", "description": "Report", "row_id": 1608685, "text": "FOCUS; ADDENDUM\nRENAL- IN PLACE OF ABG'S VBG'S CAN BE DONE SO PATIENT DOES OT HAVE TO BE STUCK.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-22 00:00:00.000", "description": "Report", "row_id": 1608686, "text": "Resp Care\nPt remains comfortable on PSV, no changes. Revieving dialysis, plan to wean to TM when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608687, "text": "micu npn 1900-0700\nplease see carevue flowsheet for all objective data\n\nneuro- pt is alert and cooperative, able to mouth words and make her needs known. She gets extremetly anxious, but responds well to verbal reassurance.\n\ncv- hr 80-90's nsr, very occ pvc's noted. bp has been mid 80's-100sys/. k 4.5 and i ca 1.09 at 2100, pt remains on ca/k gtts w/cvvhd. repeat labs to be sent at 0400.\n\nresp- remains on cpap+ps 10/5 40% fio2. rr 16-25. o2sats high90's-100%. Requires suctioning q3-4 hrs for thick white sputum, sm amts. pt has good cough.\n\ngi/gu- pt essentially aneuric overnight. continues on cvvhd w/removal rate goal of -50cc/hr. Did not tolerate this for 2-3 hrs last evening, bp dropping to mid 80's, ran even for several hrs, then problems w/prisma machene keeping her off of it x2 hrs. Resatrted ~0100 and we have been able to run her -50cc/hr since that point. pt has ileostomy that looks healthy and red in color, having sm amt of loose brown output overnight.\n\nid- afebrile. To 97.4 orally. On bair hugger most of the night. Remains ceftaz and fluconizole.\n\nendo- bs at 2300 was 82, then noted blood sugar on labs from 2100 was 58, regular and long acting insulin held overnight d/t low bs and npo status. ?to be reassessed by speech and swallow today.\n\n- duoderm over coccyx area replaced, kept off backside s-->s overnight. Has first-step air matress on her bed.\n\nsocial- updated husband by phone overnight last evening.\n\nPlan to continue cvvhd to attempt gentle fluid removal in hopes it will improve her heart function. ?tap of her pl effusions today. ?probable trial on trache collar today. to provide reassurance, support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 1608688, "text": "micu npn 1900-0700\npt received a sl ntg w/much improvement in pain, pt sleeping presently. at 0530, pt c/o chest tightness to mid sternum, indicitating that this is similar to the pain of her mi xyrs ago. ecg done w/o changes per dr . ck/enzymes to be cycled. pt received 1 mg morphine iv w/some effect. pt now c/o l neck pain as well as l back/shoulder. dr aware, debating whether to give her morte morphine at this point.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-29 00:00:00.000", "description": "Report", "row_id": 1608632, "text": "MICU Nursing Progress Note\n Respiratory: pt with bivino trach. capped and tolerating well. sat 94-96%. RR 22-28 with c/o SOb with activity.\n Neuro: A&O x3, cooperative, asking appropiate questions about care. still not really able to care for ileostomy, but asking questions about the bag.\n Cardiac: HR 70-80's NSR BP stable 140-150/80's\n Renal: foley in place and urine output maintaining 80-120cc/hr. labs pnd. HD to be re-evaluated today.\n Endocrine: stopped IV insulin gtt at and BS at 2200 300 received 20units of glargine and 5units regular insulin. AM FS 299 SS ordered for only 5units of regular.\n Plan: need to increase SS insulin to keep pt off the IV gtt. ?HD today. ?able to call out to medical floor today.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-29 00:00:00.000", "description": "Report", "row_id": 1608633, "text": "transfer note written and printed.\nRESP: BS'S CLEAR. O2 SATS 94-96%. TOL. PEGGED TRACH. DRSG . COUGHING-NOT RAISING. NO C/O SOB.\nGI: GOOD APPETITE. ILEOSTOMY DRAINING SOFT LOOSE BROWN STOOL. INTO SEE PT. AND CHANGED BAG. SITE LOOKS GOOD. NO TEARS SEEN. APPLIANCE REAPPLIED. EXTRAS IN ROOM-PLEASE SEND WITH PT. WILL FOLLOW HER WHEN TRANSFERRED.\nRENAL: U/O'S IMPROVED. QUINTON CATH FOR STANDBY FOR POSSIBLE HEMO. CREAT 2.1.\nNEURO: ALERT AND ORIENTATED.\nENDOC: SSI AND GLARGINE INCREASED FOR BETTER BS CONTROL.\nID: . ON ANTIBIOTICS. TO RECEIVE HER LAST DOSE OF VANCO. URINE APPEARED CLOUDY-SENT FOR CX. FOLEY TO BE CHANGED. NYSTATIN PDR ORDERED FOR GROIN REDNESS.\nCV: HEMODYNAMICALLY STABLE. . WITH BIL HAND EDEMA AND 1+ OF RIGHT FOOT.\n INTEGRITY: SMALL TEAR ON BUTTUCKS=DUODERM APPLIED.\nPLAN: TRANSFER TO TRANSPLANT FLOOR WHEN BED AVAILABLE ON F10.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-30 00:00:00.000", "description": "Report", "row_id": 1608634, "text": "MICU Nursing progress Note\n pt awaiting a bed on 10, uneventful night except pt unable to sleep dispite getting trazadone 25mg x2.\n Respiratory: trached, capped and tolerating well. no O2, sats range 96-98% RR low 20's\n Cardiac: HR 70-80's NSR with rare PVC's BP slightly hypertensive at start of the night, 160-170/80-90's after recieiving all her meds. BP down to 150-160/60's maintaining good u/o.\n Endocrine: FS have been high during the evening.. still trying to coordinate her eating with her insulin... did receive 26units of glargine at 2200 and 10units of humalog... 2hours later Fs down to 201.\n GI: ileostomy intact and good stool output.\n Neuro: A&)x3, cooperative, very upset unable to sleep has been second night without sleep\n Plan: stable for transfer when bed available. follow FS and treat accordingly.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-28 00:00:00.000", "description": "Report", "row_id": 1608716, "text": "micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\nNeuro- Remains withdrawn. Alert and able to communicate, mouthing words and writing on dry erase board. Follows commands\n\ncv- hr remains in nsr/st w/lots of to freq pvc's noted. ca and k gtts infusing w/cvvhd. nbp remains up, 130-150's systolic. remains on heparin gtt, increased o/n to 600u/hr to maintain theraputic ptt.\n\nresp- remains vented on cpap+ps 40% 10/5. rr teens, vt 400-450. suctioned frequently for mod amts white/yellow sputum. culture sent.\n\ngi/gu- At , ogt found to be ?out quite a bit more than previous night. Pt spitting out meds atttempted to flush down ogt. ogt pulled the rest of the way out. cxr done. Needs to readressed w/team this am. Has been npo since that time. Watching finger sticks closely overnight. Pt conts on cvvhd overnight at goal of -100cc/hr. Tolerating. ?? be able to attempt hd as her pressures have been very stable.\n\nsocial- husband calling o/n for update. remains very hopeful for her improvement and recovery.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-08-28 00:00:00.000", "description": "Report", "row_id": 1608717, "text": "micu npn 1900-0700\nqtc this shift found to be elevated from prev night .45 to .53today. Will re-check on ecg when done this am. for now holding further haldol doses.\n\nblood glucose found to be 61 this am, amp of d50 given, will recheck shortly. Priobable need to replace feeding tube today. green resident aware.\n\ngu- at 1900, ileostomy bag found to be leaking, new appliance placed w/o problem. around stoma intact, stoma site looks healthy and pink as well. putting out flatuws as well as sm amts of loose brown stool.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-28 00:00:00.000", "description": "Report", "row_id": 1608718, "text": "Resp Care Note:\n\nPt trached and on mech vent an CAVH as per Carevue. Lung sounds coarse suct sm th yellows sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. PSV.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-23 00:00:00.000", "description": "Report", "row_id": 1608658, "text": "SICU NPN:\nS-Trached\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Alert. Following commands appropriately and asking appropriate questions. MAEs. Later becoming more lethargic with temp spike, arousing to voice and following commands but less interactive. HR and BP stable. Continues to tolerate PO antihypertensive regimen. Breath sounds clear to coarse. PS decreased to 10 and tolerating well. Place back on 12 PS with temp spike due to tachypenia and improving. Suctioning infrequently for thick white secretions. No CXR done. Oliguric. Urine cloudy with sediment. Lasix 40mg IVP for hypercalcemia. Abd soft with ileostomy intact. Ostomy draining liquid brown stool. TF at GR of 35cc/hr. Temp spike to 102.6. Pan cultured including fungal blood. No adjustments in Abx regimen. Vanco trough sent and pending. Insulin gtt off at 10am. Treating with more aggressive SLSC and standing evening dose of Lantus. Husband into visit and later friend. update by RN.\n\nA/P:Failure to wean c/ source of fevers\nFollow temp curve\nWean PS as tolerated\nFollow glucoses closely\nContinue to monitor\n" }, { "category": "Nursing/other", "chartdate": "2158-07-23 00:00:00.000", "description": "Report", "row_id": 1608659, "text": "ADDEDUM TO SICU NPN:\n**Awaiting U/S of gallbladder and liver for elevated alk phos and FUO.\n" }, { "category": "Nursing/other", "chartdate": "2158-07-23 00:00:00.000", "description": "Report", "row_id": 1608660, "text": "Resp Care\nPt remains on PSV, attempted to wean ps, not tolerated pt becomes tachypnic @ times. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 1608709, "text": "MICU 7 NSG 7A-7PM\nRESP--CONTS ON PS 10 PEEP 5 40%, RR 8-18 WITH STV 400-500. SX'D Q1-4 FOR THICK FROTHY WHITE SECRETIONS. PT DENIES SOB. PLEASE SEE FOR VBG'S.\n\nCV--PT IN SR/ST WITH OCCAS PVC'S TILL ~1414 WHEN CONVERTED TO AFIB, WITH HR 100-130. MIN CHANGE IN BP, PT DENIES CP OR PALPITAIONS. 12 LEAD DONE, AND RESIDENT AWARE, PLAN IS TO OBESERVE AT THIS TIME. PT RECEIVING 1U PC'S FOR HCT 25 THIS AM. QTC 0.45. VANCO LEVEL 19.7, NO PLANS FOR DOSE THIS PM.\n\nGI--CONTS ON NOVOSOURCE PULMO CARE TF AT GOAL RATE 40CC/HR. ILEOSTOMY DRAINING SM AMOUNTS LIQUID BROWN STOOL, OB NEG. FS CHECKED Q1-4 AND RANGING FROM 82-263. SS REG CHANGED TO Q4, WITH DAILY DOSE OF NPH. PT AMP D50 FOR FS 82.\n\nNEURO--PT SLEEPING IN NAPS, BUT EASILY ROUSABLE, REQUESTED HALDOL X1 FOR ANXIETY WITH GOOD EFFECT. AFFECT FLAT, APPEARING. ABLE TO MAE, AND ASSIST WITH TURNS, PUPILS UNEQUAL DUE TO GLASS EYE.\n\nRENAL--CONTS ON CVVHDF, FLUID GOAL INC TO 100CC NET NEG PER HOUR, AND PT WELL, WITH STABLE BP. PT CONTS ON IV HEPARIN AT 300U/HR, 1600PTT PENDING AT THIS TIME. CONTS ON IV KCL AND CALCIUM GTT, TITRATED PER SS.\n\nSOCIAL--HUSBAND AND OTHER FAMILY MEMBERS IN TO VISIT, UPDATED ON PT'S CONDTION.\n\nPLAN--LABS 2200-PTT, LYTES VBG, ION CA\n--VANCO LEVEL IN AM\n--CONTS CRRT WITH NET 100CC NEG PER HOUR AS BP , IF BECOMES HYPOTENSIVE, THEN RETURN TO RUNNING EVEN\n--F/U HCT S/P TRANSFUSION\n--FOLLOW HR, WATCH FOR DEMAND ISCHEMIA\n--FS Q4 WITH HUMALOG COVERAGE Q4\n" }, { "category": "Nursing/other", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 1608710, "text": "MICU 7 NSG 7A-7PM\naddendum--pt to receive vanco 1gm iv tonight. pt received additional haldol 0.5mg iv for anxiety.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 1608711, "text": "resp care - Pt continues to be intubated with #6 Portex DIC cuffed trach on PSV 10/5 .40. Coarse BS cleared on sx of small amount of white frothy secretions. Meds given as ordered. Continued resp support planned.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 1608712, "text": "micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\nNeuro- Patient remains alert and cooperative w/care. mae, and answers q's appropriately. She appears much more this RN had seen her earlier in the week. Admits to feeling bored and anxious about being in the hospital. Anti-depressiants have been increased over the past few days, Pt is being followed by social work.\n\ncv- remains in nsr/afib both rhythms seen w/ pvc's. hr 80's- as high as 130's w/suctioning, turning, etc. remains on po amio for afib. qtc 0.45 last eve. she received her haldol dose for \"sleep\". remains on systemic heparin gtt for afib/cvvhd anti-coagulation and ?this demand ischemia vs. ami question. subtheraputic on heparin o/n, repeat one pending w/am labs. nbp has been good overnight. pt w/much vascular issues s/p 2 bipass surgeries ?radial graft from r arm.. nbp no bp or false low of 60-70's, w/ afew recycling attempts, bp returns to previous.\n\nresp- pt remains on cpap+psv10/5 40% fio2, rr teens, tv's 4-500. suctioned freq for sm amts of thick white sputum. l/s coarse\n\ngi/gu- tube feeds to pedi tube are infusing at rate of (team set goal) of 40cc/hr. She is toelrating this well. She is written to receive a dietary consult for tf recs. ileostomy putting out sm amts of liquid/loose stool. site looks health. has been 0-20cc o/n. She remains on cvvhd for fluid removal goal of -100cc and has been tolerating that.\n\nid- received vanco dose overnight. will need level drawn this am. fluconizole has been d/c'd, remaining only on ceftaz. afebrile o/n.\n\nendo- blood sugars remaining in the goal range of 200-300 overnight. Remains on humolog ss q4hrs w/long acting due in the am, has not dropped her bs overnight.\n\n Pt's husband calling for update overnight. We chatted about her multiple issues and obsticles to overcome if she is to leave the hospital at all. He remains very supportive and hopeful for recovery. Their wedding anniversary is today.\n\n pulm toileting, ?trach mask trial if able, to provide reassurance to pt and family. cvvh for fluid removal and hopeful improvement in poor ef.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 1608713, "text": "Resp Care Note:\n\nPt trached and on mech vent and CAVH. Lung sounds coarse suct mod th white sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. PSV.\n" }, { "category": "Nursing/other", "chartdate": "2158-08-27 00:00:00.000", "description": "Report", "row_id": 1608714, "text": "resp care - pt remains intubated with #6 Portex DIC trach, on PSV 10/5. No changes were made this shift. Coarse BS cleared with sx of mod amts of thick white secretions. Meds given as ordered. Plan for possible SBT tomorrow, with wean to trach collar.\n" }, { "category": "ECG", "chartdate": "2158-06-22 00:00:00.000", "description": "Report", "row_id": 126209, "text": "Atrial fibrillation or flutter\nRight bundle branch block\nPrior inferior myocardial infarction\nPrior anterolateral myocardial infarct\nNonspecific ST-T wave abnormalities\nSince previous tracing of , sinus rhythm absent\n\n" }, { "category": "ECG", "chartdate": "2158-08-26 00:00:00.000", "description": "Report", "row_id": 126157, "text": "Atrial fibrillation\nAxis indeterminate\nRight bundle branch block\nProbable prior inferior myocardial infarction\nProbable prior anterolateral myocardial infarct - although baseline artifact\nmakes assessment difficult\nDiffuse nonspecific T wave changes\nSince previous tracing of , atrial fibrillation now present\n\n" }, { "category": "ECG", "chartdate": "2158-07-16 00:00:00.000", "description": "Report", "row_id": 126167, "text": "Sinus rhythm. Right bundle-branch block. Left posterior fascicular block.\nPossible old anteroseptal myocardial infarction. Possible old inferior wall\nmyocardial infarction. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2158-06-26 00:00:00.000", "description": "Report", "row_id": 126168, "text": "Atrial fibrillation or possible flutter\nRight bundle branch block\nPrior inferior myocardial infarction\nPrior anterolateral myocardial infarct\nNonspecific ST-T wave abnormalities\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2158-08-25 00:00:00.000", "description": "Report", "row_id": 126158, "text": "Normal sinus rhythm. Right bundle-branch block with secondary ST-T wave\nabnormalities. Probable prior inferior wall myocardial infarction. Compared to\nthe previous tracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2158-08-23 00:00:00.000", "description": "Report", "row_id": 126159, "text": "Sinus tachycardia. Indeterminate axis. Right bundle-branch block. Prior\ninferior myocardial infarction. Prior anterolateral myocardial infarction.\nGeneralized low voltage. Since the previous tracing of rate is slower\nand ventricular ectopy is absent, although baseline artifact on previous\ntracing makes comparison difficult.\n\n\n" }, { "category": "ECG", "chartdate": "2158-08-21 00:00:00.000", "description": "Report", "row_id": 126160, "text": "Sinus tachycardia\nVentricular premature complex\nRight axis deviation\nRight bundle branch block\nProbable anterior myocardial infarction\nInferior infarct - age undetermined\nPossible lateral infarct - age undetermined\nLow QRS voltages in precordial leads\nSince previous tracing of , rate is increased\n\n" }, { "category": "ECG", "chartdate": "2158-08-16 00:00:00.000", "description": "Report", "row_id": 126161, "text": "Sinus rhythm. Occasional ventricular premature beat. Right bundle-branch block.\nOld transmural inferior wall myocardial infarction. Anterolateral leads are\ncompatible with old transmural infarction. Compared to the previous tracing\nof sinus tachycardia is no longer present. Transmural inferior wall\nmyocardial infarction appears to be acute as well as anteromedial and lateral\ninfarction.\n\n" }, { "category": "ECG", "chartdate": "2158-08-12 00:00:00.000", "description": "Report", "row_id": 126162, "text": "Sinus tachycardia\nMarked right axis deviation\nRight bundle branch block\nOld inferior infarct\nAnterolateral infarct - age undetermined\nLow QRS voltages in precordial leads\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2158-08-04 00:00:00.000", "description": "Report", "row_id": 126163, "text": "Sinus rhythm\nRight axis deviation\nRight bundle branch block\nPossible anteroseptal infarct - age undetermined\nPossible inferior wall myocardial infarction\nLow QRS voltages in precordial leads\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2158-08-01 00:00:00.000", "description": "Report", "row_id": 126164, "text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Prior\ninferior wall myocardial infarction. Prior anterolateral myocardial infarction.\nDiffuse ST-T wave changes. Since the previous tracing of no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2158-07-31 00:00:00.000", "description": "Report", "row_id": 126165, "text": "Sinus rhythm\nRight bundle branch block\nOld inferolateral myocardial infarct\nPossible anterior infarct - age undetermined\nLow QRS voltages in precordial leads\nBaseline artifact\nSince previous tracing, baseline artifact present\n\n" }, { "category": "ECG", "chartdate": "2158-07-18 00:00:00.000", "description": "Report", "row_id": 126166, "text": "Sinus rhythm. Left atrial abnormality. Prior inferolateral myocardial\ninfarction. Right bundle-branch block. Compared to the previous tracing\nof the ST-T wave abnormalities are somewhat more prominent in\nleads I and aVL and the rate has slowed. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2158-09-15 00:00:00.000", "description": "Report", "row_id": 126114, "text": "Technically difficult study\n*** CONSIDER ACUTE ST ELEVATION MI ***\nSinus rhythm with 1st degree A-V block\nRight axis deviation\nRight bundle branch block\n*** ANTERIOR Q WAVE INFARCT ***\nPossible lateral ST elevation\nSince previous tracing, probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2158-09-12 00:00:00.000", "description": "Report", "row_id": 126115, "text": "Technically difficult study\nSinus rhythm\nP-R interval prolonged\nMarked right axis deviation\nConduction defect of RBBB type\nAnterior Q wave consider extensive infarction - age undetermined\nLow QRS voltages in precordial leads\nSince previous tracing, no significant change\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2158-09-08 00:00:00.000", "description": "Report", "row_id": 126116, "text": "Baseline artifact. Regular rhythm, possibly sinus. Right inferior axis.\nIntraventricular conduction delay of right bundle-branch block type.\nST-T wave abnormalities. Since the previous tracing of the rate has\ndecreased and the rhythm is regular.\n\n" }, { "category": "Radiology", "chartdate": "2158-06-24 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 918309, "text": " 3:29 PM\n BILAT UP EXT VEINS US Clip # \n Reason: ASSESS CLOT\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with history of right IJ thrombosis. Assess\n thrombosis in bilateral internal jugular and subclavian veins.\n\n LIMITED VASCULAR ULTRASOUND OF BILATERAL UPPER EXTREMITIES: The study is\n limited in this patient who is deeply breathing. The echogenic material\n within right internal jugular vein, continuously down to the proximal\n subclavian vein, most likely representing partial or residual clot. Flow is\n seen in the right internal jugular vein except for the area of echogenic\n material. The distal and mid subclavian venous line could not be fully\n assessed. Normal flow and compressibility is seen in left internal jugular\n vein. There is central venous catheter from left subclavian vein. The\n assessment of subclavian vein is limited.\n\n IMPRESSION: Echogenic material within the right internal jugular vein and in\n the proximal right subclavian vein, most likely representing partial versus\n residual thrombus. Limited study due to patient motion. If indicated, please\n consider close followup.\n\n The findings were discussed with the referring physician, . by\n telephone after the completion of the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-23 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 918186, "text": " 1:12 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: Question of hydronephrosis in setting of renal transplant, d\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with h/o cadaveric renal transplant, now admitted w/ SMA\n occlusion s/p OR w/ R colectomy, now worsening renal function\n REASON FOR THIS EXAMINATION:\n Question of hydronephrosis in setting of renal transplant, decreased urine\n output, and elevated BP. Please do a doppler.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with status post renal transplant, SMA\n occlusion, worsening renal function.\n\n DOPPLER ULTRASOUND OF THE TRANSPLANTED KIDNEY: Comparison is made with the\n prior ultrasound dated . The transplanted kidney located in the\n left lower quadrant, and measures 11.8 cm, with hydronephrosis unchanged\n compared to the prior study. There are multiple echogenic foci within the\n kidneys, most likely representing air. Note is made of arterial and venous\n flow in the kidney. Resistive indices measure 0.91 in upper, 0.92 in middle,\n and 0.83 in lower, showing elevation. Note is made of small amount of fluid\n surrounding the bladder.\n\n IMPRESSION:\n 1. Stable borderline hydronephrosis in the transplant kidney.\n 2. Elevated resistive indices up to 0.99.\n 3. Multiple brightly echogenic foci in the kidney, most likely representing\n air. In this limited study in this patient who cannot hold breath, it is\n unclear if the air is in the renal parenchyma or in the collecting system.\n Further evaluation by CT scan is recommended.\n\n The findings were communicated to Dr. by person immediately after\n the completion of the study at MICU.\n\n In comparison with the CT scan subsequently performed on the same day, air\n seems to be mostly in the collecting system, and is probably iatrogenic given\n the catheter and air in the bladder. Please also refer to the official CT\n report.\n\n" }, { "category": "Radiology", "chartdate": "2158-06-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 918432, "text": " 8:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New line change of left subclavian\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F s/p with fungemia, renal failure and CHF presents with SOB, now with\n pneumonia\n REASON FOR THIS EXAMINATION:\n New line change of left subclavian\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fungemia, renal failure and CHF with shortness of breath and\n pneumonia, new line change of left subclavian.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: A left subclavian venous access catheter is in place, although the\n tip is poorly visualized and not identified beyond the level of the left\n brachiocephalic vein. Sternal suture wires, mediastinal clips, heart size and\n mediastinal contours are stable. There is continued improvement in pulmonary\n edema and stable small bilateral pleural effusions. No pneumothorax.\n\n IMPRESSION:\n 1. Left subclavian venous access catheter tip not identified due to\n technique.\n 2. Improving pulmonary edema. Stable bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 918262, "text": " 6:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F s/p with fungemia, renal failure and CHF presents with SOB, now with\n pneumonia\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Shortness of breath, pneumonia.\n\n Tracheostomy tube remains in place, unchanged in position. Left subclavian\n vascular catheter is difficult to assess due to partial obscuration by an\n overlying oxygen mask but extends at least into the distal left\n brachiocephalic vein. Cardiac and mediastinal contours are stable.\n Previously reported diffuse pulmonary opacities show interval improvement with\n residual areas of perihilar haziness, likely representing pulmonary edema. No\n new or worsening areas of consolidation are evident.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-26 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 922503, "text": " 2:56 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: video swallow\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp failure, renal failure evaluate speeck and swallow\n with video swallow\n REASON FOR THIS EXAMINATION:\n video swallow\n ______________________________________________________________________________\n FINAL REPORT\n 55-year-old female with multiple medical problems including acute renal\n failure and respiratory failure status post trach, referred for oropharyngeal\n video swallow eval.\n\n TECHNIQUE: Video oropharyngeal swallow evaluation using fluoroscopy in\n collaboration with speech therapy.\n\n FINDINGS: Patient with mildly prolonged bolus formation, though exhibiting\n good bolus control. Patient demonstrated mild spillover into the valleculae\n with thin liquids. There was mild oral residue with liquids and solids that\n took repeated swallows to clear. On pharyngeal phase, patient had mild\n swallow delay. There was mildly reduced laryngeal valve closure likely\n secondary to NG tube placement. Patient demonstrated mild to trace\n penetration of thin liquids during swallow secondary to decreased laryngeal\n valve closure on occasion. There was one episode of trace aspiration when\n taking a swallow of mixed consistency barium.\n\n IMPRESSION:\n 1. Mild to trace penetration with thin liquids.\n 2. For further details, please refer to formal swallow evaluation available\n on computerized medical records by speech therapy.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 923333, "text": " 2:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new infiltrates\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, now increased work of breathing. h/o\n fungemia, pleural effusions\n REASON FOR THIS EXAMINATION:\n ? new infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assessment for new infiltrate in a patient with dyspnea.\n\n TECHNIQUE: Portable AP view of the chest.\n\n COMPARISON: Comparison with other study done yesterday and also a study done\n two hours earlier.\n\n FINDINGS: Mild cardiomegaly is stable. Mediastinal contour is widened and\n stable. Hilar contours are normal. There are stable bilateral pleural\n effusion and atelectasis at the lung bases. There is increased interstitial\n edema comparison to the previous study. There is no pneumothorax.\n Thoracostomy is in satisfactory position at thoracic inlet. Right PICC line\n has its tip in mid SVC.\n\n IMPRESSION: Stable bilateral pleural effusion and basilar\n atelectasis/infiltrate. Worsening pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-03 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 923571, "text": " 3:40 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: r/o septic emboli\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with ESRD on HD, h/o fungemia, respiratory failure s/p trach,\n with altered mental status\n REASON FOR THIS EXAMINATION:\n r/o septic emboli\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN WITH AND WITHOUT CONTRAST\n\n CLINICAL HISTORY: Hemodialysis and fungemia. Mental status changes.\n\n TECHNIQUE: Multiplanar pre- and post-contrast T1-weighted images, axial T2-\n weighted, susceptibility FLAIR and diffusion-weighted images were obtained.\n\n Comparison is made to the CT from the preceding day.\n\n FINDINGS:\n Most of the images are limited by patient motion. There is minimal FLAIR\n hyperintensity near the lateral ventricles most likely related to small vessel\n disease. No mass effect or abnormal enhancement is seen. The ventricles and\n sulci are normal in size. A few of the mastoid air cells are opacified\n bilaterally, more easily seen on MRI than the CT of the preceding day.\n\n IMPRESSION: There are few punctate foci of FLAIR hyperintensity in the deep\n cerebral white matter perhaps related to small vessel disease. No abnormal\n enhancement is seen to suggest septic emboli.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-31 00:00:00.000", "description": "BONE SCAN", "row_id": 923083, "text": "BONE SCAN Clip # \n Reason: DM, CAD, PVD, FUNGEMIA , HYPERCALCEMIA, R/O METS\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 24.7 mCi Tc-m MDP;\n HISTORY: 55 year old woman with history of DM, CAD, PVD, fungemia, breast\n cancer, rule out metastatic disease.\n\n INTERPRETATION: Whole body images of the skeleton were obtained in anterior\n and posterior projections. These images again demonstrate a left below the knee\n knee amputation. There is note of increased generalized uptake in the right\n ankle and foot, which is more pronounced compared to the prior study dated\n , though in a similar distribution. There are otherwise no suspicious\n foci of tracer uptake to suggest metastatic disease.\n\n The left pelvic kidney and urinary bladder are visualized, with normal tracer\n excretion.\n\n IMPRESSION: 1. No evidence of osseous metastatic disease. 2. Generalized\n increased right ankle and foot, similar in distribution though more pronounced\n compared to remote prior.\n\n\n , M.D.\n , M.D. Approved: TUE 2:52 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2158-08-02 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 923328, "text": " 12:14 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: r/o mesenteric ischemia\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with fungemia\n\n REASON FOR THIS EXAMINATION:\n r/o mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen and pelvis.\n\n CLINICAL HISTORY: 55-year-old woman with fungemia. Rule out mesenteric\n ischemia.\n\n TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained after the\n administration of oral contrast, with and without IV contrast.\n\n Comparison made to prior study dated .\n\n CT OF THE ABDOMEN: There are moderate bilateral pleural effusions, right\n greater than left, with adjacent compressive atelectasis at the left lung\n base. There has been a slight interval increase in the size of the effusions.\n\n Patient is post- sternotomy. The stomach is markedly dilated. There is\n minimal perihepatic and perisplenic free fluid. Otherwise, the liver is\n normal. No intra- or extra- hepatic biliary ductal dilatation. The spleen,\n pancreas and adrenal glands are normal. The kidneys are atrophic. The small\n bowel is nondilated and unremarkable in appearance. Patient is post right\n hemicolectomy with an ostomy noted at the right lower abdomen.\n\n There are extensive vascular calcifications. Bilateral iliac artery stents\n are again seen.\n\n CT OF THE PELVIS: A transplanted kidney is in the left lower quadrant, with\n regions of cortical thinning. There is a drop of residual gas in the\n collecting system (sequence 3A, image #128), which is significantly decreased\n compared to prior study and may represent reflux from the urinary bladder.\n Foley catheter is in the urinary bladder which contains a small amount of gas.\n There is moderate pelvic free fluid. No pelvic or inguinal adenopathy.\n\n Mild degenerative changes of the spine. No suspicious osseous lesions.\n\n CTA images demonstrate the aorta and mesenteric vessels to be widely patent,\n with diffuse calcifications.\n\n IMPRESSION:\n\n 1. No evidence of mesenteric ischemia, as clinically questioned.\n (Over)\n\n 12:14 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: r/o mesenteric ischemia\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Bilateral pleural effusions with interval increase in size.\n\n 3. Markedly distended stomach.\n\n 4. Ascites.\n\n 5. Vascular calcifications.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 924339, "text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening pulmonary edema, PNA\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, h/o fungemia, retrocardiac opacity now\n with worsening SOB.\n REASON FOR THIS EXAMINATION:\n r/o worsening pulmonary edema, PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:36 a.m. on .\n\n HISTORY: Tracheostomy. Fungemia and worsening shortness of breath.\n\n IMPRESSION: AP chest compared to through 14:\n\n Mild pulmonary edema has improved since . Consolidation persisting\n at the left lung base could be either atelectasis or pneumonia. Moderate\n cardiomegaly is stable. Small left pleural effusion unchanged. Tracheostomy\n tube is in standard placement, a dual channel right supraclavicular central\n venous line ends at the superior cavoatrial junction and a nasogastric tube\n passes into the stomach and out of view. Tip of the left PIC catheter which\n goes at least as far as the left brachiocephalic vein is not clear. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 922825, "text": " 3:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o worsening pulmonary edema\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F w/ renal failure, suspected PE on trach mask now, with increasing resp\n distress\n REASON FOR THIS EXAMINATION:\n r/o worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal failure, suspected pulmonary embolism with increasing\n respiratory distress.\n\n COMPARISON: , at 9:35.\n\n AP VIEW OF THE CHEST: The patient is status post median sternotomy and CABG.\n Cardiac and mediastinal contours are unchanged. Tracheostomy tube and right\n PICC remain in unchanged standard positions. Moderate pulmonary edema and s\n mall bilateral pleural effusions, left greater than right, persist. Bibasilar\n opacities likely indicating atelectasis are unchanged. There is no\n pneumothorax. Marked calcification of the mitral annulus is again\n demonstrated.\n\n IMPRESSION: Unchanged moderate pulmonary edema with small bilateral pleural\n effusions, left greater than right, and bibasilar atelectasis.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2158-08-02 00:00:00.000", "description": "PERIPHERAL W/O PORT", "row_id": 923345, "text": " 7:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: replace possibly infected PICC. Please send tip for culture\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O PORT -59 DISTINCT PROCEDURAL SERVICE *\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\n * -59 DISTINCT PROCEDURAL SERVICE C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp distress, persistent fungemia with last PICC\n placement, on trach mask, now afebrile for > 24 hrs, blood cultures negative.\n REASON FOR THIS EXAMINATION:\n replace possibly infected PICC. Please send tip for culture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: 55-year-old woman with suspected PICC line infection.\n Needs PICC line replaced, and the tip send for culture.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: The patient's right arm and indwelling catheter were\n prepped and draped in a sterile fashion. A 0.018 guidewire was advanced\n through the catheter into the SVC, under fluoroscopic guidance. The catheter\n was then removed and a new double-lumen catheter with 40 cm long was placed\n over the wire into the distal SVC. The line was flushed and secured with a\n StatLock. The patient tolerated the procedure well. Final fluoroscopic image\n of the chest demonstrates the tip of the catheter to be located in the distal\n SVC.\n\n IMPRESSION: Successful exchange of a double-lumen catheter via the right\n basilic vein. A new double-lumen catheter with 40 cm long and tip in the\n distal SVC was placed. The line is ready for use.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-02 00:00:00.000", "description": "NON-TUNNELED", "row_id": 923346, "text": " 7:27 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Temporary HD cath placement. If possible, please exchange P\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Contrast: OPTIRAY Amt: 7\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 55 year old female with fungemia, hypercalcemia, and acute on chronic renal\n failure now requiring dialysis for electrolyte disturbances.\n REASON FOR THIS EXAMINATION:\n Temporary HD cath placement. If possible, please exchange PICC at the same\n time and culture tip.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 55-year-old female with fungemia and acute\n renal failure that required dialysis.\n\n RADIOLOGISTS: Procedure was performed by Drs. and the\n attending radiologist who was present supervising throughout the procedure.\n\n FINDINGS AND TECHNIQUE: The patient was appropriately consented and placed\n supine on the angiographic table. Timeout was performed before initiation of\n the procedure. The area of the right lower neck and chest was prepped and\n draped in sterile fashion. On ultrasound scanning, the right internal jugular\n vein could not be visualized. 5ml of 1% lidocaine was used to infiltrate\n tissues overlying the right external jugular vein for local anesthesia. Using\n ultrasound guidance, a 21- gauge needle was advanced into the right external\n jugular vein. Hard copy ultrasound images were obtained before and after\n venous access documenting vessel patency. A 0.018 guidewire was placed via the\n needle in the SVC. Its position was confirmed fluoroscopically. The needle was\n exchanged for a 4.5- French angiographic introducer sheath. The 0.018\n guidewire was exchanged for a 0.035 guidewire and the 4.5-French introducer\n was exchanged for 8, 10- and 12- French dilators. Once the venous entry tract\n was dilated, a 16 cm 14.5- French double lumen dialysis catheter was advanced\n over the wire with the tip positioned within the right atrium. Excellent flow\n was obtained through both ports. The line was secured to the skin with 2.0\n silk suture and sterile dressing.\n\n IMPRESSION: Successful placement of a right non-tunneled external jugular\n dialysis catheter with the tip in the right atrium. The line is ready for\n use.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-05 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 923828, "text": " 10:54 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: r/o DVT, has PICC line in this arm\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with h/o thrombus of neck veins per patient, pls eval for\n patency, for purposes of re-siting central line in neck.\n REASON FOR THIS EXAMINATION:\n r/o DVT, has PICC line in this arm\n ______________________________________________________________________________\n FINAL REPORT\n 55-year-old female with history of thrombus in the neck with PICC line and\n concern for upper extremity DVT.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the\n right internal jugular, subclavian, axillary, brachial, cephalic and basilic\n veins were performed. There is normal compressibility, waveform, augmentation\n and flow. No intraluminal echogenic material is identified.\n\n IMPRESSION: No evidence of DVT in the right upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 923429, "text": " 5:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: place verify NG tube placement\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, h/o fungemia, s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n place verify NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old with chronic tracheostomy and fungemia, check NG tube\n placement.\n\n SINGLE AP UPRIGHT PORTABLE CHEST: Compared to study of earlier same day.\n Study is limited by technique and motion. Right-sided IJ line is seen with\n its tip in the proximal right atrium. Apparent PICC line is seen with its tip\n in the distal SVC. There is a third line tip in the distal SVC, its etiology\n unclear. Tracheostomy tube seen unchanged. Mediastinal wire is unchanged in\n position. Cardiac silhouette is enlarged, although much of this may be\n technical. Interval NG tube placement with its tip in the body of the\n stomach. There is a probable left retrocardiac density, and probable mild\n congestive heart failure.\n\n IMPRESSION:\n 1) Satisfactory NG tube placement with its tip in the body of the stomach.\n 2) Interval right-sided central venous line with its tip in the proximal right\n atrium; no pneumothorax.\n 3) Persisting left retrocardiac opacity and probable mild CHF/volume overload.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 922843, "text": " 5:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o fungal CNS pathology\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM\n CLINICAL HISTORY: The air-fluid levels are noted in the sphenoid sinus\n suggestive of acute sinusitis. CT of the sinuses is recommended for further\n evaluation.\n\n\n\n 5:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o fungal CNS pathology\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with persistent fungemia through fluconazole now with AMS.\n REASON FOR THIS EXAMINATION:\n r/o fungal CNS pathology\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent fungemia.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: There is no evidence for intracranial hemorrhage. There is no mass\n effect or shift of normally midline structures. The ventricles, cisterns, and\n sulci maintain a normal appearance. There is atherosclerotic calcification of\n the cavernous carotids, and vertebral arteries. The osseous structures are\n unremarkable. The visualized paranasal sinuses are clear. Note of a left\n phthisis bulbi.\n\n The patient is status post left enucleation with left global prosthesis.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 923981, "text": " 12:06 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: L picc\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, h/o fungemia, retrocardiac opacity.\n\n REASON FOR THIS EXAMINATION:\n L picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Confirmation of left PICC placement.\n\n COMPARISON FILM: .\n\n PORTABLE CHEST X-RAY: There is interval removal of a right PICC line and\n placement of left PICC line with tip terminating in the right atrium. No\n evidence of pneumothorax.\n\n IMPRESSION: Interval placement of left PICC line with tip terminating in the\n right atrium.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 923302, "text": " 5:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F w/ C. albicans fungemia, hypercalcemia, and worsening acute on chronic\n renal failure now with elevated WBC, change in MS.\n FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old woman with albicans fungemia, hypercalcemia, and\n worsening acute on chronic renal failure now with elevated white blood cell\n count and change in mental status.\n\n COMPARISON: .\n\n AP CHEST: There is stable cardiomegaly. The aorta is calcified and tortuous.\n Compared to prior exam, there appears to be worsening pulmonary edema and\n increase in the left pleural effusion. There continues to be left lower lobe\n consolidation, which could represent atelectasis, however, an underlying\n pneumonia cannot be excluded. Tracheostomy, surgical clips, sternotomy wires,\n and right-sided PICC are again noted. Osseous and soft tissue structures are\n stable.\n\n IMPRESSION: Worsening moderate pulmonary edema. Left lower lobe\n consolidation could represent atelectasis, however, an underlying pneumonia\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 923817, "text": " 9:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, overload\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, h/o fungemia, s/p NG tube placement\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, overload\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION PERFORMED: AP chest.\n\n INDICATION FOR STUDY: Chronic tracheostomy. Nasogastric tube placement.\n Single AP view of the chest is obtained at 21:07 hours and is compared\n with the prior radiograph of . There is diffuse cardiomegaly. There is\n persistent increased density in the retrocardiac area on the left side\n consistent with atelectasis/airspace disease. Increased density in the left\n mid zone of the lung likely also represents atelectasis. Bilateral pleural\n effusions appear likely, more marked on the left side. Tubes and lines appear\n unchanged except the NG tube tip is not included on the current image.\n\n IMPRESSION:\n\n 1. Persistent retrocardiac density consistent with atelectasis/airspace\n disease.\n\n 2. Bilateral pleural effusions.\n\n 3. Likely mild failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 918092, "text": " 8:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate vs edema. has left subclavian in place\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F s/p with fungemia, renal failure and CHF presents with SOB\n REASON FOR THIS EXAMINATION:\n infiltrate vs edema. has left subclavian in place\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fungemia, renal failure, CHF, infiltrate versus edema.\n\n COMPARISON: .\n\n FINDINGS: The lung volumes are low. There is increased opacification of both\n lungs with some areas demonstrates more focal ill-defined opacification. The\n left diaphragmatic border is obscured by left lower lobe opacity. There is\n a small left pleural effusion. The cardiac and mediastinal contours are\n stable. The patient is status post CABG. Tracheostomy is unchanged. A left\n central venous catheter tip projects over the left brachiocephalic and\n superior vena caval junction.\n\n IMPRESSION: Left lower lobe opacity and increased ill-defined opacities in\n both lungs likely secondary to multifocal pneumonia, but limited evaluation\n secondary to low lung volumes. Repeat PA and lateral chest radiograph would\n be helpful for further evaluation.\n\n Dr. and I discussed these findings at 10:00 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2158-07-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 920971, "text": " 3:38 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia and assess for pleural effusion.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n who presents today with increasing productive cough.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia and assess for pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE STUDY: Ruling out pneumonia and assessing for pleural\n effusion.\n\n TECHNIQUE: AP upright is compared to the previous study done on .\n\n FINDINGS: Mild pulmonary edema is improved compared to previous study.\n Moderate layering left pleural effusion is stable. Bibasilar atelectasis is\n noted. Left subclavian jugular sheath tip projects over the left subclavian\n vein.\n\n IMPRESSION: No evidence of pneumonia. Moderate-sized left pleural effusion\n is stable . Mild pulmonary edema, improving.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 919557, "text": " 11:31 AM\n CHEST (PA & LAT) Clip # \n Reason: change in effusions or development of any new consolidation\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with increasing SOB.\n\n REASON FOR THIS EXAMINATION:\n change in effusions or development of any new consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing shortness of breath, evaluate for change in effusions\n or development of new consolidation.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: A tracheostomy tube is in place with tip terminating 2.3 cm from\n the carina. There is stable moderate cardiomegaly and low lung volumes.\n Since the previous examination, bilateral pleural effusions, left greater than\n right, appear unchanged. Mild pulmonary edema is slightly increased.\n\n IMPRESSION: Cardiomegaly and slight increase in pulmonary edema. Stable\n bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-19 00:00:00.000", "description": "LUNG SCAN", "row_id": 921533, "text": "LUNG SCAN Clip # \n Reason: DM, CAD, PVD, FUNGEMIA, AND RENAL FAILURE, NOW WITH DYSPNEA R/O PE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 5.2 mCi Tc-m MAA;\n 42.0 mCi Tc-99m DTPA Aerosol;\n HISTORY: 55 yo woman h/o DM, CD, PVD, fungemia & renal failure now with dyspnea\n ? PE\n\n\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate aerosol\n deposition about her tracheostomy tube. There is mostly homogeneous lung uptak\n but there is a significant defect the the left lower lobe.\n\n Perfusion images in the same 8 views show a matching perfusion defect in the\n left lower lobe.\n\n Images suggest fluid in the fissures.\n\n Chest x-ray shows opacification of the left lower lobe and effusions.\n\n The above findings are consistent with a low likelihood ratio for PE.\n\n FOR ALL HIGH PROB PE EXAMS,\n A) THE REFERRING PHYSICIAN MUST BE CALLED\n B) THE CALL MUST BE DOCUMENTED IN THIS REPORT ALONG WITH THE NAME OF THE\n PHYSICIAN \n\n IMPRESSION:\n Low likelihood ratio for pulmonary embolism.\n\n\n , M.D.\n , M.D. Approved: FRI 2:32 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2158-07-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 919922, "text": " 6:14 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Question of infection and fluid overload.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Field of view: 35\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with fluid overload and increasing SOB, despite increased\n diuresis.\n REASON FOR THIS EXAMINATION:\n Question of infection and fluid overload.\n CONTRAINDICATIONS for IV CONTRAST:\n Resolving acute on chronic renal failure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fluid overload and increasing shortness of breath, despite\n increased diuresis. Question infection or fluid overload.\n\n TECHNIQUE: CT chest without contrast.\n\n Comparison is made to .\n\n CT OF THE CHEST WITHOUT CONTRAST: The endotracheal tube is located with a tip\n approximately 5 cm above the carina. There are bilateral moderate to large\n pleural effusions, which have increased in size since the prior study. There\n is adjacent compressive lateral atelectasis. There are new multifocal nodular\n and patchy consolidations involving all lung lobes, which are concerning for a\n disseminated infectious process given the patient's history of fungemia. There\n also is right hilar lymphadenopathy, which may have been present on the prior\n study. Geographic opacities in the periphery of the anterior aspect of both\n upper lobes are stable and consistent with prior radiation treatment for\n bilateral breast cancer.\n\n There is stable mild cardiomegaly. There is no evidence of pulmonary edema.\n The patient is status post median sternotomy and CABG. Again seen is a ring-\n like calcification in the left breast, possibly representing dystrophic\n calcification from fat necrosis.\n\n In the imaged portion of the upper abdomen again noted is severe calcification\n of the celiac axis. A partially visualized left atrophic kidney is seen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n 1. Interval development of multifocal consolidations concerning for a\n disseminated infectious process. Given the history of breast cancer,\n metastatic disease is a consideration but less likely given the short interval\n timeframe.\n 2. Increase in bilateral pleural effusions, now moderate to large and right\n greater than left, with adjacent compressive atelectasis.\n 3. Stable post radiation changes within the anterior upper lobes bilaterally\n related to treatment for breast cancer.\n 4. Stable moderate cardiomegaly.\n (Over)\n\n 6:14 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Question of infection and fluid overload.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Field of view: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 919299, "text": " 6:48 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia or worsening effusions.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with increasing SOB.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia or worsening effusions.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PA AND LATERAL VIEWS\n\n REASON FOR EXAM: 55-year-old woman with increasing SOB, rule out pneumonia.\n\n Comparison is made with prior study .\n\n FINDINGS: There is no pneumothorax, pulmonary consolidation. Left subclavian\n venous line is unchanged in position with tip just below the level of the left\n brachiocephalic vein. Continued improvement in pulmonary edema is seen.\n Stable bilateral pleural effusions. Heart size and mediastinal contours are\n unchanged. Patient is S/P median sternotomy.\n\n IMPRESSION: Improving pulmonary edema. Stable bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2158-06-23 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 918214, "text": " 3:33 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Gas in the kidney by US. Evaluate if the gas is in the \n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with severe ab pain , h/o mesenteric ischemia s/p R\n hemicolectomy 1 week ago, now abd pain and elevated WBC on immunosuppressants\n\n REASON FOR THIS EXAMINATION:\n Gas in the kidney by US. Evaluate if the gas is in the bladder or in the\n parenchyma of the kidney.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe abdominal pain. History of mesenteric ischemia status\n post right hemicolectomy. Now with elevated white count and gas in the kidney\n by ultrasound.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast axial CT imaging of the abdomen and pelvis was\n reviewed.\n\n CT ABDOMEN WITHOUT CONTRAST: Multiple ill-defined patchy opacities within the\n lung bases, likely secondary to an infectious process. Evaluation of the lung\n bases is limited secondary to significant respiratory motion. Bilateral\n pleural effusions and concomitant atelectasis is unchanged. The patient is\n status post median sternotomy. Evaluation of the liver is limited secondary\n to respiratory motion and artifact, but no focal lesions are identified. There\n is a small amount of ascites about the liver. Pancreas not well identified.\n The spleen is small. Extensive atherosclerotic calcification of the aorta and\n major branches including the splenic artery, celiac artery, and SMA are\n present. The adrenal glands are poorly visualized. Both kidneys are\n atrophic. Small bowel loops are normal caliber. The patient is status post\n diverting ileostomy.\n\n CT PELVIS WITH CONTRAST: Transplant kidney is present in the left lower\n quadrant. Moderate air is present within multiple calices and is new from\n prior exam. Mild hydronephrosis is present, unchanged. There is no evidence\n for fat stranding about the transplant kidney or pernephric fluid collections.\n Air is present within the bladder. A Foley catheter is present. Small ascites\n is present in the pelvis. The rectum and sigmoid is unremarkable. The patient\n is status post right colectomy. No pathologic adenopathy is present.\n Increased soft tissue density and edema is present within the subcutaneous\n soft tissues. The patient is status post common iliac stenting, bilaterally.\n\n IMPRESSION:\n\n 1. Air within the transplant kidney collecting systems, new from comparison.\n Given new appearance and clinical history, this likely represents\n (Over)\n\n 3:33 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Gas in the kidney by US. Evaluate if the gas is in the \n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n emphysematous pyelonephritis. Reflux from air seen in bladder possibly due\n to indwelling Foley catheter is another possiblity. No evidence for\n perinephric fat stranding or fluid collections. Correlation with renal\n ultrasound is advised to assess graft function.\n\n 2. Ill-defined patchy opacities in the lung bases, likely infectious.\n Bilateral pleural effusions and associated atelectasis. Small ascites about\n the liver and in the pelvis, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-17 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 921323, "text": " 5:16 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: question of further worsening or improvement of bilateral pu\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with resolving fluid overload, cough, and history of new\n development of pulmonary nodules.\n REASON FOR THIS EXAMINATION:\n question of further worsening or improvement of bilateral pulmonary nodules\n CONTRAINDICATIONS for IV CONTRAST:\n s/p renal transplant with worsening Cr\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of patient with fever, cough and history of\n developed new pulmonary nodules\n\n COMPARISON: Chest CT from and .\n\n TECHNIQUE: Non-enhanced MDCT of the chest from thoracic inlet to upper\n abdomen was obtained with 1.25 and 5 mm collimation axial images reviewed.\n\n FINDINGS:\n\n The patient is after median sternotomy and CABG with stable appearance of the\n post-surgical clips. The native coronary arteries are heavily calcified. The\n main pulmonary artery is markedly dilated up to 4 cm as well as both right and\n left pulmonary arteries, 2.7 and 2.2 cm respectively. The heart size is\n enlarged. The mitral annulus calcifications are significant. There is no\n pericardial effusion. The bilateral pleural effusions, right more than left,\n have been slightly increased since the previous exam.\n\n There is no mediastinal, hilar, axillary or mammarian lymphadenopathy.\n\n The pulmonary window images demonstrate stable post radiation bilateral\n changes in the upper lobes in a patient with a history of breast cancer.\n Several small pulmonary nodules, predominantly located in the upper lobes\n (right greater than left), series 3, images 12, 13, 19, 21, 26 are grossly\n unchanged since and are new in comparison to . The\n right apical consolidation, series 3, image 11, the left perihilar\n consolidation, series 3, image 24 and bilateral bibasilar atelectases are also\n unchanged since . The airways are patent to the level of\n segmental bronchi. The tip of the tracheostomy is 5 cm below the vocal cords.\n\n The images of the upper abdomen demonstrate bilateral atrophic kidney in\n patient with known longstanding end stage renal disease. There are prominent\n calcifications of the celiac trunk and renal arteries. There is mild ascites\n which seems to be slightly increased in comparison to the previous study. The\n liver, the spleen, and the adrenals are unremarkable. The pancreas is\n atrophic. Mild ascites has been slightly increased.\n\n There are no lytic or sclerotic lesions suspicious for malignancy.\n\n (Over)\n\n 5:16 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: question of further worsening or improvement of bilateral pu\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1) Persistent upper lobe predominant small nodules which could represent\n known fungal infection. However, their relative stability during the last 14\n days and new appearance since , also raises the possibility of mets\n or lymphoproliferative disorder, especially in the setting of asymmetrical\n thickening with slight nodularity of the interlobular septa in the right upper\n lobe. Short- term CT followup in 4 to 6 weeks is recommended to assess whether\n these findings respond to treatment for presumed infection. If persistent or\n growing at follow-up, mets should be considered.\n\n 2) Persistent foci of lung consolidation which could also be related to\n fungal infection but other infection such as bacterial origin cannot be\n excluded.\n\n 3) Slightly increased bilateral moderate pleural effusions, right more than\n left.\n\n 4) Pulmonary hypertension.\n\n 5) Cardiomegaly. Severe arthrosclerotic disease.\n\n 6) Bilateral atrophic kidneys.\n\n 7) Mild increased ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-17 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 921320, "text": " 5:06 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess bowel loops\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with loose stools and mild distension on abdominal exam.\n REASON FOR THIS EXAMINATION:\n assess bowel loops\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with loose stool and mild distention on\n abdominal exam.\n\n SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: Comparison was made with prior\n abdominal radiograph dated . Note is made of dilated gas in the\n left upper quadrant, most likely representing stomach. Paucity of the bowel\n gas is noted. The patient is status post stents in bilateral iliac arteries.\n There is small bilateral pleural effusion. The patient is status post CABG\n with median sternotomy. There are bibasilar opacities, representing\n atelectasis Vs. consolidation bilaterally.\n\n IMPRESSION: Dilated gas in the left upper quadrant most likely representing\n stomach. Paucity of the bowel gas. Bilateral pleural effusions and opacities\n in lower lobes. Please correlate clinically, and follow with additional\n imageing to exclude develop small bowel obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 921704, "text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval changes\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F w/ renal failure, suspected PE on trach mask now, with increasing resp\n distress\n REASON FOR THIS EXAMINATION:\n ? interval changes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE STUDY: Assessment for interval change in a patient with PE\n with increasing respiratory distress.\n\n TECHNIQUE: Portable AP view and is compared to the previous study done on\n .\n\n FINDINGS: There has been no change in appearance of the lungs since previous\n study. There is persistent hilar congestion and bilateral reticular opacity.\n There are bilateral pleural effusions, more obvious on the left side.\n Thoracostomy tube is at thoracic inlet. NG tube has its tip in the stomach.\n There is a left subclavian sheath catheter that has its tip in the left\n brachiocephalic vein.\n\n IMPRESSION: Mild pulmonary edema unchanged . Bilateral mild pleural\n effusion, more dominant on the left side.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 921141, "text": " 10:55 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n who presents today with increasing productive cough and continued low-grade\n fever on immunosuppresion.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post renal transplant and fungemia, low grade fever.\n\n CHEST: The heart remains enlarged. Bilateral effusions are present. There\n is loss of the left hemidiaphragm and a left lower lobe infiltrate or\n atelectasis cannot therefore be excluded. Comparison with the prior chest\n x-ray which is best on the lateral film shows no significant change.\n\n IMPRESSION: No significant change. Bilateral effusions persist. Left lower\n lobe infiltrate could be present.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 918124, "text": " 5:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change, now with pneumonia\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F s/p with fungemia, renal failure and CHF presents with SOB, now with\n pneumonia\n REASON FOR THIS EXAMINATION:\n Interval change, now with pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fungemia, renal failure, and congestive heart failure, now with\n pneumonia.\n\n COMPARISON: .\n\n CHEST: AP upright portable view. The tracheostomy tube remains in unchanged,\n satisfactory position. Allowing for lower lung volumes, previously noted\n diffuse interstitial pulmonary opacities are unchanged, consistent with either\n pulmonary edema or diffuse pneumonia, including atypical pneumonia. Evidence\n of CABG is again noted. Small bilateral pleural effusions are probably\n present. Left lower lobe atelectasis is unchanged. Left subclavian venous\n catheter is again noted, with tip in the left brachiocephalic vein just to the\n right of the spine.\n\n IMPRESSION:\n 1. Unchanged diffuse pulmonary opacities, which may represent pulmonary\n edema, diffuse pneumonia, or combination of both.\n\n 2. Unchanged left basilar atelectasis or consolidation. Unchanged small\n bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 921364, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA vs pulm cong\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F w/ renal failure and UTI\n\n REASON FOR THIS EXAMINATION:\n ?PNA vs pulm cong\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Single AP portable view of the chest.\n\n REASON FOR EXAM: 54-year-old female with renal failure and UTI. Question\n pneumonia versus pulmonary congestion.\n\n COMPARISON: Comparison is made with prior study dated .\n\n FINDINGS: There are large bilateral pleural effusions, right greater than\n left with associated bibasilar atelectasis, wich allowing the difference in\n patient position and technique are unchanged. The left heart border is\n obscured by the atelectasis and pleural effusions. Patient is status post\n median sternotomy and CABG. Tracheostomy tube in adequate position.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-18 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 921447, "text": " 4:22 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SWELLING FEVERS\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with history of fungal PNA with new SOB and hypoxia\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with a history of fungal pneumonia and new\n shortness of breath and hypoxia. Evaluate for DVT.\n\n COMPARISON: .\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and color Doppler son\n was performed of the right common femoral, superficial femoral, and popliteal\n veins. Normal flow, waveforms, compressibility, and augmentation are\n identified. No intraluminal thrombus is identified.\n\n IMPRESSION: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-23 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 922073, "text": " 1:16 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEV. ALK PHOS, EVAL FOR CHOLESTASIS, CBD DIL\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with elevated alk phos, fevers. Please check RUQ ultrasound\n REASON FOR THIS EXAMINATION:\n evaluate for cholestasis, CBD dilation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with elevated ALT, fever.\n\n LIVER AND GALLBLADDER ULTRASOUND: Comparison is made with the prior CT scan\n dated .\n\n FINDINGS: The liver is unremarkable without evidence of focal liver lesions\n or intrahepatic ductal dilatation. The gallbladder is contracted, however,\n there is no stone or pericholecystic fluid. Portal flow is normal. CBD\n measures 3 mm. No evidence of ascites.\n\n IMPRESSION: Contracted gallbladder, without cholecystic fluid or gallstones.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 920173, "text": " 3:30 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Assess for pneumothorax\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n Assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis, question pneumothorax.\n\n CHEST, SINGLE AP VIEW.\n\n Kyphotic positioning, with neck and chin obscuring the apices. Also the side\n of the thoracentesis is not indicated. I cannot exclude a tiny right apical\n pneumothorax. No other evidence for pneumothorax is detected on this film.\n Again seen are sternotomy wires and mediastinal clips, prominent ill-defined\n cardiomediastinal silhouette, left lower lobe collapse and/or consolidation,\n and small left effusion. Probable background CHF.\n\n Findings discussed with Dr. at 3:47 p.m. on the day of the exam.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 920214, "text": " 10:33 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: Please perform CXR at 11pm. assess pneumothorax as compared\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp and fungemia who is s/p thoracentesis from today\n with evidence of small pneumothorax on patient's post-thoracentesis CXR.\n REASON FOR THIS EXAMINATION:\n Please perform CXR at 11pm. assess pneumothorax as compared to CXR from \n afternoon.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess pneumothorax.\n\n chest, 2 vws\n\n There is a very small right apical pneumothorax, minimally larger than on the\n film from 3:30 p.m. on . There is upper zone redistribution and\n diffuse vascular blurring, consistent with CHF. There is left lower lobe\n collapse and/or consolidation. Status post sternotomy with mediastinal clips.\n\n IMPRESSION:\n\n 1. Very small right apical pneumothorax, slightly larger than on the film\n from last night.\n\n 2. CHF findings, slightly worse than on the film from last night. Left lower\n lobe collapse and/or consolidation, unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 920143, "text": " 11:27 AM\n CHEST (PA & LAT) Clip # \n Reason: question of left-sided pleural effusion\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp and fungemia with increasing SOB, decreased\n breath sounds at left lower base, and new onset of bilateral pulmonary nodules.\n\n REASON FOR THIS EXAMINATION:\n question of left-sided pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post renal transplant, fungemia with increasing shortness of\n breath, decreased breath sounds, left base.\n\n CHEST, TWO VIEWS.\n\n The patient is status post sternotomy, with mediastinal clips. Tracheostomy\n is in place. There is a left subclavian central line with tip overlying the\n innominate vessel, unchanged. No pneumothorax is identified. There is\n prominence of the cardiomediastinal silhouette, unchanged. There is upper\n zone redistribution and diffuse vascular plethora, with a small-to-moderate\n left and probable small right pleural effusion. There is left lower lobe\n collapse and/or consolidation.\n\n IMPRESSION: Pulmonary edema with left and probable small right pleural\n effusion. Left lower lobe collapse and/or consolidation. Degree of\n opacification in the left mid zone is increased compared with .\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925974, "text": " 12:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, other cause of chest pain\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal\n failure with chest pain\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, other cause of chest pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant. Evaluate for pneumonia or other\n cause of chest pain.\n\n COMPARISONS: .\n\n AP SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: A right-sided double lumen central\n venous catheter is unchanged in position. The tracheostomy tube has a very\n short intratracheal component; clinical correlation is recommended to verify\n correct tube positioning. There is mild interval decrease in the amount of\n pleural effusions. Opacity at the left lung base again may represent\n atelectasis, but pneumonia cannot be excluded. The left-sided PIC line\n terminates at the cavoatrial junction. There has been interval placement of\n an NG tube with the partially seen tip projecting over the expected position\n of the gastric fundus.\n\n IMPRESSION:\n 1. Interval decrease in amount of bilateral pleural effusions.\n 2. Left basilar atelectasis, less likely pneumonia.\n 3. No new consolidations are appreciated.\n 4. Please verify correct tracheostomy tube position.\n 5. NG tube placement with tip projecting over the gastric fundus.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926217, "text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PLease evaluate for interval stability of effusions/opacitie\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n with CHF on CVVHD\n REASON FOR THIS EXAMINATION:\n PLease evaluate for interval stability of effusions/opacities\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal transplant with fungemia. Evaluate for effusions and\n pneumonia.\n\n PORTABLE AP CHEST RADIOGRAPH: Limited study given patient's severe rotation\n and exclusion of right hemithorax. Compared to prior exam from , persistent left basilar opacity is seen which may represent atelectasis\n vs. air space disease. Otherwise, cardiomediastinal silhouette is grossly\n unchanged and NG tube is seen below the diaphragm though the distal tip has\n been excluded. If further evaluation is warranted, please repeat chest\n radiograph with the inclusion of the right hemithorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-09-04 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 927422, "text": " 10:32 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: RT ARM SWELLING, EVAL FOR RIGHT UPPER EXTREMITY THROMBUS\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with h/o thrombus of neck veins per patient, now with upper\n extremity edema\n REASON FOR THIS EXAMINATION:\n pls eval for right upper extremity thrombus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with history of thrombus of neck veins per\n patient. Now with upper extremity edema. Evaluate for thrombus.\n\n COMPARISON: .\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND:\n\n -scale and Doppler son of the right internal jugular, subclavian,\n axillary, brachial, and basilic veins were performed. Normal compressibility,\n augmentation, flow, and waveforms are demonstrated. No evidence of\n intraluminal thrombus.\n\n IMPRESSION:\n\n No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928103, "text": " 11:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please rule out infectious process\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n now with hallucinations, delusions\n REASON FOR THIS EXAMINATION:\n please rule out infectious process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rule out infectious process in a patient with acute on chronic renal\n failure, fungemia status post renal transplant, now with hallucinations.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n There is markedly rotated positioning. The patient is status post sternotomy,\n with probable cardiomegaly. A tracheostomy is in place. A right IJ central\n line is in place, tip over distal SVC. Left hemidiaphragm is not well\n demonstrated and could reflect some left lower lobe collapse and/or\n consolidation. A small left effusion cannot be excluded. No overt CHF is\n identified, but mild CHF would also be difficult to exclude due to the\n atypical positioning.\n\n Compared with and allowing for considerable differences in positioning,\n no definite change is identified. There may have been slight interval\n improvement in the degree of CHF. The left lower lobe opacity is grossly\n unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-08 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 927944, "text": " 6:32 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: FALL\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with multiple medical problems including DM, CAD, ESRD,\n breast cancer, fungemia, who fell out of bed- unwitnessed fall.\n REASON FOR THIS EXAMINATION:\n Please evaluate for bleed, masses.\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 55-year-old woman with multiple medical problems including\n breast cancer and fungemia, status post unwitnessed fall.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intra- or extra-axial hemorrhage.\n Ventricles, cisterns, and sulci are unremarkable without effacement. There is\n no mass effect, hydrocephalus, or shift of the normally midline structures.\n There is polypoid mucosal thickening in the sphenoid sinus. The mastoid air\n cells are clear. Prosthetic globe on the left is unchanged.\n\n IMPRESSION: No evidence of significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-09-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 928903, "text": " 5:46 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with worsening mental confusion and sputum\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with worsening mental confusion and sputum.\n\n COMPARISON: .\n\n AP AND LATERAL CHEST RADIOGRAPHS: The patient is status post CABG and median\n sternotomy wires are seen. A right internal jugular central venous catheter\n is in unchanged position. There is no pneumothorax. The cardiomediastinal\n silhouette is unchanged. There are small bilateral pleural effusions. There\n is a persistent left retrocardiac opacity. A left perihilar opacity may\n represent consolidation or asymmetric edema.\n\n IMPRESSION:\n\n 1. New left perihilar opacity representing consolidation or asymmetric\n pulmonary edema.\n\n 2. Bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926782, "text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval changes\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal\n failure who presents today with increasing productive cough and continued\n low-grade fever on immunosuppresion.\n REASON FOR THIS EXAMINATION:\n ? interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 8:16 A.M., ON .\n\n HISTORY: Renal transplant and fungemia. Increasing cough and fever.\n\n IMPRESSION: AP chest compared to through :\n\n Small bilateral pleural effusiona have decreased since . Mild\n pulmonary edema and moderate cardiac silhouette enlargement are unchanged.\n Left lower lobe consolidation, could be atelectasis or pneumonia, is\n unchanged. Feeding tube ends in the lower stomach. Right supraclavicular\n central venous dual catheter tip projects over the mid SVC. The line passes\n into the right atrium, tip is indistinct. Tracheostomy tube in standard\n placement. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925822, "text": " 10:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change in effusion, pulm edema\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n who presents today with increasing productive cough and continued low-grade\n fever on immunosuppresion.\n REASON FOR THIS EXAMINATION:\n eval for change in effusion, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant with fungemia and acute on chronic\n renal failure. Increasing productive cough and continued fever. Evaluate for\n change in effusion and pulmonary edema.\n\n .\n\n AP UPRIGHT RADIOGRAPH OF THE CHEST: A right-sided double lumen central venous\n catheter and endotracheal tube remain in stable position. There is slight\n interval increase in the amount of pleural effusion, predominantly on the\n left. Consolidation at the left lung base likely represents atelectasis and\n pneumonia cannot be excluded. The left-sided PIC line terminates at the\n cavoatrial junction.\n\n IMPRESSION: Interval increase in pulmonary edema, predominantly on the left.\n Left basilar opacity likely represents atelectasis, but pneumonia cannot be\n excluded.\n\n" }, { "category": "Radiology", "chartdate": "2158-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926500, "text": " 8:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for new infiltrates/consolidations\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n with tube feeds in mouth, ? aspiration\n REASON FOR THIS EXAMINATION:\n Please evaluate for new infiltrates/consolidations\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute on chronic renal failure. Evaluate for aspiration\n pneumonia.\n\n CHEST: The heart is enlarged. There is perihilar prominence suggesting\n cardiac failure. There is loss of the left hemidiaphragm and this could be\n caused by fluid and/or atelectasis/consolidation.\n\n IMPRESSION: Evidence of failure, cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925636, "text": " 2:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? source of SOB\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, h/o fungemia, retrocardiac opacity now\n with worsening SOB.\n REASON FOR THIS EXAMINATION:\n ? source of SOB\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:20 A.M. \n\n HISTORY: Chronic tracheostomy. Fungemia. Worsening shortness of breath.\n\n IMPRESSION: AP chest compared to through 17:\n\n Moderate-to-severe large bilateral pleural effusion increased since .\n Stable large cardiac silhouette. More severe consolidation at the base of the\n left lung could be atelectasis or pneumonia. No pneumothorax. Tip of the\n left PIC catheter projects over the superior cavoatrial junction.\n Dual-channel right supraclavicular central venous line ends in the upper SVC.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926552, "text": " 11:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate or consolidations\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n with ? aspiration on \n REASON FOR THIS EXAMINATION:\n please eval for infiltrate or consolidations\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute on chronic renal failure, SOB.\n\n CHEST: There has been no significant change since the prior chest x-ray of\n the 3rd. Bilateral effusions are present. Probable left lower lobe\n infiltrate is present. Perihilar edema consistent with failure is again\n noted.\n\n IMPRESSION: No change. Failure and probable left lower lobe infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926575, "text": " 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ngt placemenent\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p renal tp, fungemia, and acute on chronic renal failure\n who presents today with increasing productive cough and continued low-grade\n fever on immunosuppresion.\n REASON FOR THIS EXAMINATION:\n ngt placemenent\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Renal failure, increasing cough and fever.\n\n CHEST: The tip of the nasogastric tube lies in the region of the antrum. The\n heart is enlarged. Bilateral pleural effusions are seen. Pantaloon graft is\n seen in the distal aorta and iliac vessels.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 923959, "text": " 9:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate pulmonary edema, PNA\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with chronic trach, h/o fungemia, retrocardiac opacity.\n REASON FOR THIS EXAMINATION:\n evaluate pulmonary edema, PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Fungemia and pulmonary edema.\n\n Various lines and tubes are unchanged in position. Allowing for rotation,\n there is stable enlargement of cardiac silhouette. Lung volumes are lower on\n the current study than before, likely accentuating the bronchovascular\n structures. There are persistent bilateral lower lobe opacities in the\n retrocardiac areas, as well as persistent bilateral pleural effusions. There\n has been apparent slight worsening of previously reported mild failure, but\n lower lung volumes could potentially contribute to this apparent change.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-09-11 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 928369, "text": " 8:11 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please assess for subacute stroke, evidence of metastatic di\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with ESRD s/p renal transplant, DM1, h/o breast cancer now\n has new-onset hallucinations/delusions\n REASON FOR THIS EXAMINATION:\n please assess for subacute stroke, evidence of metastatic disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please assess for subacute stroke. 55-year-old woman with\n end-stage renal disease and renal transplant. New delusions and\n hallucinations.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through\n the brain with multiplanar post-gadolinium T1 imaging.\n\n FINDINGS: The study is limited due to patient motion artifact. The\n preliminary report by the on-call resident, , indicates there is\n no evidence of infarction and the exam is too limited to exclude small\n metastases, but no large lesions are identified.\n\n There are no enhancing masses. There is no midline shift, mass effect or\n hydrocephalus. Due to patient motion artifact, small metastases in the areas\n of enhancement cannot be excluded but there are no large masses. There are no\n large areas of T2 signal abnormality. There are multiple tiny foci of\n increased signal in the FLAIR sequence in the periventricular and subcortical\n white matter of both cerebral hemispheres likely represent chronic\n microvascular ischemic changes. There is no slow diffusion to indicate an\n acute infarct. There are no areas of abnormal magnetic susceptibility.\n\n There is fluid in both mastoid sinus air cells, right greater than left, which\n could be consistent with mastoiditis in the right clinical setting.\n\n IMPRESSION: Slightly limited due to patient motion artifact.\n\n No acute infarct. No enhancing lesions. Small amounts of chronic\n microvascular ischemic change.\n\n Within both mastoid, sinuses could be consistent with mastoiditis in the right\n clinical setting.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2158-08-11 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 924551, "text": " 4:40 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o worsening pulmonary edema, PNA, evaluate effusions.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with resolving fluid overload, PNA and persistent SOB.\n REASON FOR THIS EXAMINATION:\n r/o worsening pulmonary edema, PNA, evaluate effusions.\n CONTRAINDICATIONS for IV CONTRAST:\n recent ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Resolving fluid overload, pneumonia, and persistent shortness of\n breath.\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: Chest x-ray of and .\n\n Bilateral moderate-to-large pleural effusions, more on the right. Atelectasis\n noted in both lower lobes and the apicoposterior segment of the left upper\n lobe. Ground glass opacities and interlobular septal thickening is consistent\n with pulmonary edema. There is cardiomegaly. The patient is status post CABG\n with median sternotomy. The upper paratracheal node measures up to 13 mm.\n There is no pericardial effusion.\n\n Noncalcified 5-mm nodule in the right upper lobe. Most of the pulmonary\n nodules seen on the prior CT of are not appreciated on today's\n study. However, a followup CT should be obtained after treatment to the\n underlying congestive heart failure for evaluation of primary pathology such\n as metastasis.\n\n In the upper abdomen, the kidneys are small and atrophic. The liver, spleen,\n and adrenals are unremarkable. Note made of a tracheostomy tube in standard\n position.\n\n A calcific density is noted in the left breast, which is partially imaged\n (please see separately dictated mammogram report for details).\n\n There are no osteolytic or osteoblastic lesions suspicious for malignancy.\n\n IMPRESSION:\n 1. Cardiomegaly with bilateral-to-moderate pleural effusions with pulmonary\n edema are findings suggestive of congestive heart failure and bilateral lower\n lobe atelectasis and atelectasis in the left upper lobe.\n 2. Noncalcified pulmonary nodule in the right upper lobe, however most of the\n pulmonary nodules, as compared to the prior CT of have resolved.\n Few of these could get obscured by the underlying effusion which has increased\n in the interval and a followup CT should be obtained after treatment of the\n (Over)\n\n 4:40 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o worsening pulmonary edema, PNA, evaluate effusions.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n underlying CHF or after tapping the effusions.\n 3. Stable mediastinal lymphadenopathy, attributable to chronic congestive\n heart failure.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2158-07-27 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 922722, "text": " 7:59 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: r/o kidney as source of infection.\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with h/o cadaveric renal transplant, now admitted w/ SMA\n occlusion s/p OR w/ R colectomy, now fungemic\n REASON FOR THIS EXAMINATION:\n r/o kidney as source of infection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cadaveric transplant. Please evaluate kidney for\n source of current infection.\n\n FINDINGS: -scale and color Doppler son of the transplant kidney\n were performed. There is mild hydronephrosis, unchanged. Previously\n identified air within the calices has resolved. Renal artery Doppler is\n within normal limits with the resistive indices ranging from 0.72-0.73. Renal\n vein is patent. There is no perinephric fluid.\n\n IMPRESSION: Stable renal transplant.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 923327, "text": " 12:14 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute mental status changes\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with fungemia\n REASON FOR THIS EXAMINATION:\n acute mental status changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Fungemia and altered mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: The study is slightly degraded by motion artifact, despite having\n been repeated. There is no acute intracranial hemorrhage. There is no mass\n effect or shift of normally midline structures. The ventricles, cisterns and\n sulci maintain a normal configuration, and the -white matter\n differentiation is preserved,. There is sclerosis of the right mastoid tip,\n and probable small fluid level in the right sphenoid sinus, as before, but the\n mastoid air cells and visualized paranasal sinuses are otherwise clear. The\n patient is status post enucleation of the left globe, with prosthesis in situ.\n\n IMPRESSION:\n 1. No acute hemorrhage or cerebral edema.\n 2. Possible right sphenoid sinus inflammatory disease.\n\n COMMENT: Contrast-enhanced MR examination would be more sensitive for cerebral\n complications of known fungemia.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 922763, "text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54F w/ renal failure, suspected PE on trach mask now, with increasing resp\n distress\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal failure with suspected pulmonary embolism and increasing\n respiratory distress.\n\n COMPARISON: .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: New right PICC tip terminates in the mid\n SVC. Tracheostomy tube remains in standard unchanged position. The patient\n is status post median sternotomy and CABG. Moderate pulmonary edema is worse,\n and moderate cardiomegaly has increased. Increasing small bilateral pleural\n effusions, left greater than right, with worsening bibasilar atelectasis is\n present. No pneumothorax.\n\n IMPRESSION:\n 1. Worsening moderate pulmonary edema and increasing moderate cardiomegaly.\n 2. Increasing small bilateral pleural effusions and bibasilar atelectasis.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2158-08-01 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 923324, "text": " 11:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o free air\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with loose stools and mild distension on abdominal exam.\n\n REASON FOR THIS EXAMINATION:\n r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assessment for free air in a patient with abdominal distention.\n\n TECHNIQUE: Portable AP view of the chest.\n\n COMPARISON: Available from yesterday.\n\n FINDINGS: Stable mild cardiomegaly. Mediastinum widened and is stable.\n Hilar contours are normal. There are stable bilateral pleural effusion and\n worsening of interstitial edema. The stomach is distended with gas. There is\n no free intra-abdominal air.\n\n IMPRESSION: No free intra-abdominal air or severe distention of stomach.\n Stable bilateral effusion and atelectasis at lung bases. Worsening pulmonary\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-01 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 923325, "text": " 11:45 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o free air, obstruction in setting change in abdominal exa\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with loose stools and mild distension on abdominal exam.\n\n REASON FOR THIS EXAMINATION:\n r/o free air, obstruction in setting change in abdominal exam\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with loose stools and mild distention on exam.\n\n SUPINE ABDOMEN: The stomach is distended with air and fluid. There is a\n relative paucity of air in small and large bowel loops. Ascites is\n identified on the subsequent CT. There are extensive vascular calcifications,\n and iliac stents are noted. Surgical clips are observed in the left inguinal\n region. Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: Stomach distended with air and fluid. Relative paucity of gas in\n the small and large bowel.\n\n" }, { "category": "Radiology", "chartdate": "2158-07-25 00:00:00.000", "description": "PICC W/O PORT", "row_id": 922321, "text": " 11:27 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: IR PICC placement\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp distress, now on trach mask, fevers, now afebrile\n for > 24 hrs\n REASON FOR THIS EXAMINATION:\n IR PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: IV access; fevers. Needs access and antibiotics.\n\n PROCEDURE: This procedure was performed by Dr. , with Dr. present\n and supervising throughout as the attending. The right upper arm was prepped\n and draped in the usual sterile fashion. As no suitable veins were found on\n visual inspection, ultrasound was used to identify the right basilic vein,\n which was patent and compressible. Approximately 3 ml of 1% lidocaine were\n administered for local anesthesia, and the right basilic vein was accessed\n using real-time ultrasound guidance. Hard copy ultrasound images were\n obtained before and after venipuncture documenting vessel patency. After\n venipuncture was performed, a 0.018 guidewire was advanced through the wire\n and into the SVC under fluoroscopic guidance. The needle was exchanged for a\n 4 French micropuncture sheath. Based on the markers on the guidewire the PICC\n was trimmed to 42 cm, then the inner dilator withdrawn and the PICC threaded\n over the wire under fluoroscopic guidance into the distal SVC. The peel-away\n sheath was removed, and the wire was removed. The catheter was flushed,\n heplocked, then StatLocked. A final fluoroscopic image was taken to\n demonstrate the tip of the PICC in the distal SVC.\n\n There were no immediate complications. The patient tolerated the procedure\n well.\n\n IMPRESSION: Successful placement of 42 cm double lumen PICC in distal SVC via\n the right basilic vein. The line is ready for use.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-08-04 00:00:00.000", "description": "P BLADDER US PORT", "row_id": 923719, "text": " 7:11 PM\n BLADDER US PORT Clip # \n Reason: ? fungal ball in bladder\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with s/p renal tx, renal failure, fungemia on IV Caspo, urine\n growing yeast. ? presence of fungal ball in the bladder\n REASON FOR THIS EXAMINATION:\n ? fungal ball in bladder\n ______________________________________________________________________________\n FINAL REPORT\n 54-year-old female status post renal transplant and renal failure with\n fungemia and urine growing yeast with concern for fungal ball and bladder.\n\n BLADDER ULTRASOUND: There is floating echogenic debris within the bladder,\n but no mass lesion or discrete fungal ball is identified. The patient is\n catheterized.\n\n IMPRESSION: Floating debris within the urinary bladder is nonspecific. No\n mass or fungal ball is identified.\n\n" }, { "category": "Radiology", "chartdate": "2158-09-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 928298, "text": " 1:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please r/o acute bleed\n Admitting Diagnosis: FUNGEMIA;BREAST CANCER;STATUS POST KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with ESRD s/p transplant, DM1, recent ICU stay for fungemia,\n VAP, with recent history of supratherapeutic INR now has\n hallucinations/delusions\n REASON FOR THIS EXAMINATION:\n Please r/o acute bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Supratherapeutic INR with delusions and hallucinations.\n Evaluate for acute bleed.\n\n COMPARISON: CT head with contrast from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: No hemorrhage or mass. No shift of normally midline structures.\n The ventricles, cisterns, and sulci maintain a normal configuration. No major\n vascular territorial infarct is apparent. The small air fluid level in the\n right lateral sphenoid sinus is unchanged. Otherwise, the mastoid air cells\n and the visualized paranasal sinuses are clear. The prosthetic left eye is\n noted once again.\n\n IMPRESSION: No hemorrhage. Normal brain imaging.\n\n" } ]

[ { "category": "Echo", "chartdate": "2167-03-30 00:00:00.000", "description": "Report", "row_id": 62908, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 65\nWeight (lb): 235\nBSA (m2): 2.12 m2\nBP (mm Hg): 153/101\nStatus: Inpatient\nDate/Time: at 12:31\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated. No spontaneous echo contrast\nis seen in the body of the left atrium or left atrial appendage. No\nmass/thrombus is seen in the left atrium or left atrial appendage.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. No\nspontaneous echo contrast is seen in the body of the right atrium or right\natrial appendage. No mass or thrombus is seen in the right atrium or right\natrial appendage. A left-to-right shunt across the interatrial septum is seen\nat rest. A secundum type atrial septal defect is present.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter. The descending thoracic aorta\nis normal in diameter. There are simple atheroma in the descending thoracic\naorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. There is no\nsignificant aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is no significant mitral stenosis. Trivial mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast is seen in the\nbody of the left atrium or left atrial appendage. No mass/thrombus is seen in\nthe left atrium or left atrial appendage. No spontaneous echo contrast is seen\nin the body of the right atrium or right atrial appendage. No mass or thrombus\nis seen in the right atrium or right atrial appendage. A left-to-right shunt\nacross the interatrial septum is seen at rest. A secundum type atrial septal\ndefect is present. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. There are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened. There is no significant\naortic valve stenosis. 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 no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2167-04-06 00:00:00.000", "description": "Report", "row_id": 117067, "text": "Sinus bradycardia. Long QTc interval. Consider anteroseptal myocardial\ninfarction with ST-T wave configuration making for age indeterminate - may also\nbe ischemia. Since the previous tracing of , no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-04-05 00:00:00.000", "description": "Report", "row_id": 117068, "text": "Sinus bradycardia. Prolonged Q-T interval. Anterolateral ST-T wave\nabnormalities - cannot exclude ischemia. Diminutive R waves in leads V2-V3\nraise the consideration of prior anteroseptal myocardial infarction. Clinical\ncorrelation is suggested. Since the previous tracing of further\nprecordial ST-T wave abnormalities are present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2167-04-02 00:00:00.000", "description": "Report", "row_id": 117069, "text": "Sinus rhythm\nLow QRS voltages\nST-T abnormalities V1-V2 may be normal variant-cannot exclude ischemia\nSince previous tracing, , ventricular premature complexes absent and\nST-T abnormalities in leads V1-2 present (? lead position change)\n\n" }, { "category": "ECG", "chartdate": "2167-04-01 00:00:00.000", "description": "Report", "row_id": 117070, "text": "Sinus rhythm with ventricular ectopy. Left atrial abnormality. Low limb lead\nvoltage. Modest non-specific low amplitude T waves. Since the previous tracing\nof the QTc interval has decreased, ventricular ectopy is seen and\nST-T wave changes have decreased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-03-31 00:00:00.000", "description": "Report", "row_id": 117071, "text": "Sinus rhythm. Borderline prolonged QTc interval. Left atrial abnormality.\nConsider prior inferior myocardial infarction. Diffuse ST-T wave abnormalities\n- cannot exclude ischemia or possible metabolic - drug effect. Since the\nprevious tracing of QTc interval appears more prolonged and further\nT wave changes are present. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2167-03-31 00:00:00.000", "description": "Report", "row_id": 117072, "text": "Sinus rhythm. Left atrial abnormality. Non-diagnostic inferior acute\nQRS changes, but consider prior inferior myocardial infarction. Non-specific\nright precordial T wave changes. Since the previous tracing of right\nprecordial T wave changes are present. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-03-30 00:00:00.000", "description": "Report", "row_id": 117073, "text": "Sinus rhythm. Consider left atrial abnormality. Non-diagnostic inferior\nQRS changes, but consider possible prior inferior myocardial infarction. Since\nthe previous tracing of , no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2167-03-29 00:00:00.000", "description": "Report", "row_id": 117074, "text": "Atrial fibrillation with a moderate ventricular response. Consider prior\ninferior myocardial infarction. Since the previous tracing of the\nventricular rate is slightly faster.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-03-28 00:00:00.000", "description": "Report", "row_id": 117075, "text": "Atrial fibrillation with a controlled ventricular response. Consider prior\ninferior myocardial infarction. Since the previous tracing of no\nsignificant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2167-03-27 00:00:00.000", "description": "Report", "row_id": 117076, "text": "Atrial fibrillation with a controlled ventricular response. Consider prior\ninferior myocardial infarction. Modest non-specific ST-T wave changes. Since\nthe previous tracing of no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2167-03-26 00:00:00.000", "description": "Report", "row_id": 117077, "text": "Atrial fibrillation with a moderate ventricular response. Consider prior\nanterior myocardial infarction. Modest diffuse non-specific ST-T wave changes.\nSince the previous tracing earlier this date the rhythm is more indicative of\natrial fibrillation.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-04-07 00:00:00.000", "description": "Report", "row_id": 117020, "text": "Sinus rhythm. Prolonged QTc interval. Anteroseptal myocardial infarction with\nST-T wave configuration which makes age indeterminate. Inferior QRS changes are\nnon-diagnostic but consider possible prior inferior myocardial infarction.\nSince the previous tracing of , no significant change.\n\n" }, { "category": "ECG", "chartdate": "2167-03-26 00:00:00.000", "description": "Report", "row_id": 117078, "text": "Right and left arm leads have been reversed. Atrial flutter with a rapid\nventricular response. consider prior inferior myocardial infarction.\nNon-specific ST-T wave abnormalities. Since the previous tracing of \natrial flutter is now present and precordial T wave changes are less prominent.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2167-03-31 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 753057, "text": " 5:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for expansion of known retroperitoneal bleed\n Field of view: 44\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with CAD, HTN, AFib, on anticoagulation, now w/ bilat\n thigh/inguinal/back pain, hct drop 10 points today.\n REASON FOR THIS EXAMINATION:\n please evaluate for expansion of known retroperitoneal bleed found on ct scan\n yesterday\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 year old woman with CAD, hypertension, atrial fibrillation, on\n anticoagulation therapy. Retroperitoneal hematoma was diagnosed by CT on\n . Presents with a 10 point decrease in hematocrit level, and bilateral\n thigh and back pain.\n\n COMPARISONS: .\n\n TECHNIQUE: Contiguous axial images of the abdomen and pelvis were obtained\n without intravenous contrast.\n\n ABDOMINAL CT WITHOUT CONTRAST: The lung bases show new small bilateral pleural\n effusions with associated minimal dependent atelectasis. The liver,\n gallbladder, pancreas, spleen, stomach, small and large bowel, kidneys,\n adrenal glands and intraabdominal great vessels are unchanged.\n\n There is a new large soft tissue mass associated with musculature of the left\n lateral abdominal wall, projecting in the abdomen. This most likely represents\n a new large hematoma. Previously visualized hematomas in the left psoas,\n possibly right psoas and right iliacus muscles are unchanged. There is mimimal\n fat stranding around the areas of hematoma formation.\n\n PELVIC CT WITHOUT CONTRAST: The urinary bladder contains contrast and the\n balloon of a Foley catheter. The pelvic organs are unchanged from the prior\n study. There is a small amount of fluid with surrounding fat stranding in the\n pelvis.\n\n The osseous structures show degenerative changes of the spine. Incidentally\n seen is an injection granuloma in the soft tissues of the right buttock.\n\n IMPRESSION:\n 1. New small bilateral pleural effusions with associated minimal dependent\n atelectasis.\n 2. New large hematoma of the left lateral abdominal wall, projecting medially\n into the abdomen.\n 3. Small amount of free fluid in the pelvis.\n 4. Unchanged hematomas in bilateral psoas and right ilacus muscles.\n\n\n (Over)\n\n 5:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for expansion of known retroperitoneal bleed\n Field of view: 44\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2167-03-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 752949, "text": " 3:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: HCT DROP,BIL THIGH/BACK PAIN,R/O RETROPERITONEAL BLEED\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with CAD, HTN, AFib, on anticoagulation, now w/ bilat\n thigh/inguinal/back pain, hct drop overnight.\n REASON FOR THIS EXAMINATION:\n Rule out retroperitoneal bleed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Hematocrit drop overnight, r/o retroperitoneal bleed.\n\n COMPARISONS: .\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n femoral heads after administration of 150 cc of Optiray. Nonionic contrast\n was used secondary to patient's debility.\n\n CT ABDOMEN WITH CONTRAST: The lung bases are clear. The liver, gallbladder,\n spleen, pancreas, adrenals, and kidneys appear normal. There is no mesenteric\n or retroperitoneal adenopathy. There is a 3.1 x 2.6 cm low attenuation area\n within the left psoas muscle, consistent with a left psoas hematoma. There is\n interval increase in soft tissue stranding surrounding this area. A small\n hiatal hernia is demonstrated. Vascular calcifications are identified in the\n aorta and proximal iliacs.\n\n CT PELVIS WITH CONTRAST: Sigmoid diverticulosis is identified without\n evidence for diverticulitis. The vascular loops of large and small bowel are\n otherwise unremarkable. The distal ureters and bladder are unremarkable.\n\n There is no pelvic free fluid or lymphadenopathy.\n\n Bone windows demonstrate no suspicious lytic or sclerotic abnormalities.\n\n IMPRESSION:\n\n 1. Findings consistent with left psoas hematoma. This finding is unlikely to\n account for a large hematocrit drop.\n\n 2. Diverticulosis without evidence for diverticulitis.\n\n 3. Small hiatal hernia.\n\n\n\n (Over)\n\n 3:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: HCT DROP,BIL THIGH/BACK PAIN,R/O RETROPERITONEAL BLEED\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2167-04-01 00:00:00.000", "description": "Report", "row_id": 1492036, "text": "MICU NURSING ADDENDUM:\nCPK at pm 3354. Dr. aware, checking am cpk.\nContinue to follow cpk, and cpk mb trends.\n" }, { "category": "Nursing/other", "chartdate": "2167-04-01 00:00:00.000", "description": "Report", "row_id": 1492037, "text": "7A-7P MICU NPN\n\nNEURO: PT IS ALERT AND ORIENTED X3. VERY PLEASANT DURING CARE. NO NEURO SYMPTOMS NOTED.\n\nRESP: ON O2 AT 2L VIA NC AND O2 SAT FLUCTUATES BETWEEN 94-98% AND DENIED ANY SOB.\n\nCV: MAP HAS BEEN IN THE 70'S. HR 80'S-90'S W/ OCC PVC'S. LAST HCT 34.3.\n\nGI: POS BOWEL SOUNDS NOTED, RESUMED CARDIAC DIET, PT HAD 180ML OF SOUP AROUND 6PM AND TOLERATING WELL.\n\nGU: FC INTACT VOIDING >30ML OF CLEAR YELLOW URINE.\n\nIV: ON NS AT 120ML/HR\n\nPLAN: TO CONT MONITOR HCT LEVEL AND ANY SIGNS OF BLEEDING. NEXT HCT LEVEL 8PM TONIGHT. PT BE D/C TO REG UNIT TOMORROW IF HCT IS STABLE.\n\nPT RECEIVED TYLENOL 650MG PO X2 FOR RIGHT LEG PAIN AND H/A WITH GOOD EFFECT.\n\nCODE STAUS: FULL\n" }, { "category": "Nursing/other", "chartdate": "2167-04-02 00:00:00.000", "description": "Report", "row_id": 1492038, "text": "NURSING PROGRESS NOTE:\nPT ALERT AND ORIENTED X 3. VERY PLEASANT AND COOPERATIVE.\nC/O RIGHT LEG PAIN AND WAS MED WITH OXYCODONE AND EXTRA STRENGTH TYLENOL FOR A HA WITH RELIEF. PT SLEPT WELL THROUGH THE NIGHT.\nHR IN 60'S TO 70'S WITHOUT ECTOPY AND MAINTAINING A GOOD BP. IV CONT AT 120/HR FOR 2LITERS DUE TO ELEVATED CK'S.\nFOLEY CATH PATENT DRAINING ADEQ AMT'S OF CLEAR YELLOW URINE.\nTAKING PO'S WITHOUT DIFF.\nABLE TO HELP WITH TURNING.\nHCT AT 8PM STABLE, WILL MOST LIKELY BE CALLED OUT TO THE FLOOR IN THE AM.\nPT REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2167-04-02 00:00:00.000", "description": "Report", "row_id": 1492039, "text": "micu- nursing\npt.stransfred to ,vs-wnl,stable,no c/o cp;sob,floor rn at bedside,repor given.\n" }, { "category": "Nursing/other", "chartdate": "2167-04-01 00:00:00.000", "description": "Report", "row_id": 1492034, "text": "MICU Nursind Admission Note:\n73 year old female who presented to hospital on with new onset aflutter with a 2:1 block. Pt. converted to afib adn was started on heparin and coumadin and underwent TEE/CV on . On pt. began c/o pain in her back, which progressed to the R thigh. CK's began trending up adn HCT decreased to 36 from 32. HCT continued to drop and pt. had a ct scan which revealed a hematoma in psoas. Pt. given blood, however HCT continued to decrease. On , Bp decreased in the 80's pt. lethargic, hct 20. Pt. had repeat ct scan, which showed new and expanding hematomas, given 4 U prbc's and 2u ffp and brought to MICU for close observation.\n\nPMHX: HTN\n Hyperlipidemia\n hypothyroidism\n h/o pancreatitis\n hearing loss\n cholethiasis\n osteoarthritis\n\nNeuro: Alert and oriented x3, able to move all extremeties. No c/o pain in extremeties, and actually stated that she is able to move much better today. Pt. resting comfortably.\n\nResp: On 2l nc, lungs CTA, sat's in the 90's. No c/o SOB.\n\nCV: Bp initially stable with MAP >60 and SBP in the 90-110. However when pt. asleep, and as HCT decreased her map decreased into the 40's. with a SBP in the 70-80's. Dr. aware, pt. given 2 500cc NS boluses with increase in BP and MAP. See carevue. HR in the 70's NSR, no ectopy noted.\n\nGI: Currently npo except meds and ice chips. ACtive bowel sounds, no stool.\n\nGU: URine output has been marginal. 25-50cc/hr. Foley to gravity.\nSkin: intact.\nACCESS: 2 peripheral 20 guages. NS @kvo currently.\nHEME: AFter pt. became hypotensive repeat hct 26.5 at 11pm decreased from 31 @9pm. Pt. to be given 2U prbc's. and will continue to follow hct.\nSee carevue for further data.\n" }, { "category": "Nursing/other", "chartdate": "2167-04-01 00:00:00.000", "description": "Report", "row_id": 1492035, "text": "MICU Nursing Addendum:\nNeuro: Pt. sleeping most of the night. When awakened is alert and oriented x3. Able to assist with turning, although is weaker in her R leg.\n\nResp: Remains on 2L NC, lungs are CTA, sat's 98%. No c/o SOB.\n\nCV: Low BP was initially supported with NS fluid boluses and blood products. Bp is now stable 90-100/40-50 with MAP in the 60-70 range. NSR with occ pac.\n\nGU: Urine output has increased with fluid, and blood intake.\n\nHEME: Pt. given a total of 3U prbc's after 11pm HCT was 26.5. INR 1.6 and Per Dr. pt. given additional 2u FFP. PT. tolerated transfusions well without any reaction. Will send repeat labs this am.\nSee carevue for further data.\n\nPlan: COntinue to follow BP, and serial HCT and PT/ptt.\n Asses for signs and symptoms of bleeding.\n If HCT continues to decrease and pt. becomes unstable, may need to go to interventional radiology for embolization of bleeding area.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 987950, "text": " 8:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o injury\n Field of view: 35.4 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman unrestrained driver, starred windshield, intubated for\n combativeness/confusion\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg FRI 9:49 PM\n right 8 and 9th rib fracture with underlying grade 2 hematoma or biloma within\n the liver.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old female, unrestrained driver, starred\n windshield, intubated for combativeness, confusion. Rule out injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced MDCT-acquired axial images of the chest,\n abdomen, and pelvis from the thoracic inlet to the pubic symphysis.\n Multiplanar reformatted images were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs are clear. The heart\n and great vessels are within normal limits. The aorta maintains a normal\n contour. No pleural or pericardial effusion is identified. Flame shaped soft\n tissue is seen within the anterior mediastinum, consistent with residual\n thymic tissue. A tiny locule of gas is seen within the left lateral\n pectoralis major muscle.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Liver shows a 2cm low\n attenuating area within segment VIII of the liver, extending to the capsule\n and adjacent to fractured ribs, likely representing a small intraparechymal\n hematoma versus a biloma - grade II injury.\n\n The gallbladder, spleen, adrenal glands, kidneys, pancreas and intraabdminal\n loops of large/small bowel are within normal limits. No intra-abdominal free\n air, free fluid, or lymphadenopathy is apparent. The abdominal aorta\n maintains a normal contour. The celiac, SMA, and are normally opacified.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\n uterus are within normal limits. The adnexa are not well seen. A normal\n bladder is seen containing a Foley catheter. No free fluid or lymphadenopathy\n is apparent.\n\n BONE WINDOWS: Fractures are identified involving the right eighth and ninth\n anterolateral ribs.\n\n IMPRESSION: Right anterolateral eighth and ninth rib fractures.\n (Over)\n\n 8:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o injury\n Field of view: 35.4 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Hypoattenuation focus is seen subjacent to the fractures within segement VIII\n of the liver and extending to the capsule, most consistent with a small\n hematoma of biloma, consistent with a grade II liver injury.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 987951, "text": " 8:52 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: r/o fractures, facial injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with R eye/face lac s/p unrestrained driver in MVC\n REASON FOR THIS EXAMINATION:\n r/o fractures, facial injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg FRI 9:48 PM\n no fracture.\n WET READ VERSION #1 KYg FRI 9:36 PM\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 32-year-old female with a right eye, face laceration status\n post unrestrained driver in a motor vehicle collision. Rule out fracture,\n facial injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the facial bones.\n Multiplanar reformatted images were obtained.\n\n FINDINGS: No fracture is identified involving the sinuses or orbits. The\n globes and intraconal fat is preserved. The visualized paranasal sinuses and\n mastoid air cells remain normally aerated. A moderate-sized right periorbital\n hematoma is present. ET tube and pool secretions within the /oropharynx\n is noted.\n\n IMPRESSION: No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 987948, "text": " 8:47 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o cspine injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman unrestrained driver, intubated for combativeness/confusion\n REASON FOR THIS EXAMINATION:\n r/o cspine injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg FRI 9:33 PM\n no fracture or subluxation.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old female, unrestrained driver, intubated for\n confusion, combativeness. Rule out C-spine injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT acquired axial images of the cervical spine from\n the skull base to the level of T1. Multiplanar reformatted images were\n obtained.\n\n FINDINGS: Cervical spine maintains a normal alignment. No subluxation or\n fracture is identified. The prevertebral soft tissues are within normal\n limits. Pooled secretions are seen within the oral and nasopharynx. ET tube\n is present. Visualized paranasal sinuses and mastoid air cells remain normally\n aerated.\n\n IMPRESSION: No evidence of fracture or subluxation.\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 987947, "text": " 8:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: fine cuts of maxillofacial bones please r/o intracranial inj\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman unrestrained driver, starred windshield, GCS 12, intubated\n for combativeness and confusion, large lac above R eye and face\n REASON FOR THIS EXAMINATION:\n fine cuts of maxillofacial bones please r/o intracranial injury, facial\n fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg FRI 9:08 PM\n no hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old unrestrained female driver, starred windshield,\n GCS 12, intubated for combativeness and confusion. Large laceration above\n right eye. Evaluate for injury.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: No hemorrhage, hydrocephalus, or shift of normally\n midline structures. The -white matter differentiation is preserved. No\n major vascular territorial infarct is apparent. The paranasal sinuses and\n mastoid air cells remain normally aerated. No fracture is identified. There\n is a right periorbital hematoma. The globes and intraconal fat is preserved.\n\n IMPRESSION: No hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2123-12-03 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 987945, "text": " 8:32 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old female status post motor vehicle collision.\n Evaluate for injury.\n\n COMPARISON: None.\n\n AP CHEST: Trauma board obscures fine detail. No consolidation, pneumothorax\n or pleural effusion is identified. The cardiomediastinal contours are within\n normal limits. Right lateral eighth rib fracture is identified. ET tube\n terminates approximately 4 cm above the carina.\n\n AP PELVIS: No fracture or dislocation is identified.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-12-04 00:00:00.000", "description": "Report", "row_id": 1649381, "text": "Respiratory Care:\nPt recieved orally intubated and vented. Pt weaned to PS 5, PEEP 5.RSBI this am 62. Tolerated well, VT 350-500, RR 16-22, SpO2 100%. Pt extubated, good cuff leak heard prior to extubation.Placed on 35% cool aerosol, SpO2 100%.\n" }, { "category": "Nursing/other", "chartdate": "2123-12-04 00:00:00.000", "description": "Report", "row_id": 1649382, "text": "Nursing Note 7am-7pm\n\nROS: See carevue for exact data\n\nEvents of today--> Extubated 1400\n Cspine/TLS cleared\n Social work involvement\n Serial Hct's\n\n22 yr old admitted afte MVC with husband. Injuries included right rib fx 8 and 9, ? grade 2 hematoma to the liver.\n\nAllergies: to Pcn and Sulfa (per husband)\n\nN: Pt sedated on propofol most of the morning. Held for neuro exams. Initially while on propofol pt not following commands, slow at times to arouse off 60 mcg. Arousing very agitated/restless,moving all exts very purposeful in the bed with normal strength . Pt attempting to sit bolt upright, pulling at tube. . Dr. comfortable around 1500 to extubate. Propofol off and pt extubated this afternoon. Since extubation agitation resolved but pt slightly anxious, crying at times. Hoarse voice, pt confused initially to place, but aware she was at the hospital, oriented to date/yr. Some weakness to right shoulder, per pt this shoulder has been an issue for a while, Dr. aware. Pt c/o some pain to ribs, slight HA. Pain meds held initially due to pt able to fall instantly asleep and still groggy from sedative. Morphine ordered prn. Pupils equal bilat at 3mm. Wrist restraints d/c'd.\nCV: BP stable 110-130's systolically. HR 90-105 SR-St. No ectopy. Fluids changed to D5 @ 75. Pulses palpable. Venodynnes on\nResp: Ls slightly coarse, diminished at bases. Pt able to cough up secretions. sats 99-100%.\nGI: OGT d/c'd Pt remains NPO till appears more alert. Abd soft, pos BS.\nGu: U/o adeq 30-100 per hr, slightly green from propofol\nSkin: Right facial abrasion cleansed with peroxide and triple anbx oint applied. Rest of skin intact.\nHem: Serial hcts with slight drop throughout the day. Dr. aware. Last hct drawn at 1800 next due at 2400 despite written order for 2200. 1800 drawn late.\nEndo: Bld sugars stable and d/c'd.\nID: Temp max 99.6, no iv anbx.\nSoc: Pt with multiple social issues eluded through husband. Pt expressing sadness of the loss of her newborn son. Social work called, and involved.\nPlan: Cont to monitor neuro status, medicate for pain. Monitor resp status, encourage cough and deep breathing. Advance diet when more awake. will d/c foley when up and oob. Wound care as ordered. CTLS clr'd. Social work to continue to follow. Emotional support provided. Cont serial hct, transfer to floor status if pt remains stable. Monitor\n" }, { "category": "Nursing/other", "chartdate": "2123-12-04 00:00:00.000", "description": "Report", "row_id": 1649379, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick clear secretions.RSBI done on 0 peep/5 ips 60. Sedated with propofol. Will cont to monitor resp status and wean to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2123-12-04 00:00:00.000", "description": "Report", "row_id": 1649380, "text": "T/SICU NURSING ADMISSION NOTE\n\nPt is a 22y/o female transfered from s/p MVC, unrestrained passenger, moderate front end damage, starred windshield. Negative ETOH. Pt intubated for combativeness at OSH, pan scan negative. Pt transfered to , scans repeated. CT chest/abdomen showed right ribs 8&9 fx with underlying grade 2 hematoma or biloma within the liver. Pt to T/SICU for serial HCTs, plan for extubation once TLS films cleared.\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt sedated on Propofol at 60mcgs/kg/min, off sedation pt strongly/purposefully MAE's however will not follow commands. Pupils bilaterally and brisk, strong cough and gag. Head CT negative. Fentanyl PRN for pain. C-collar intact, logroll precautions.\n\nCV-NSR-low ST 90-100's no ectopy. PIVx2, one remains from outside hospital. SBP 110's-120's and stable. Transient bradycardia noted at OSH, none since admission. Compression boots for prophylaxis, no SC heparin at this time. Q4hour hcts, slight drift this am 39.1 down to 34.7, ?dilutional, continuing to monitor.\n\nRESP-Pt orally intubated #7.5ETT, 21LL on CMV TV 450, R 12, P5 50%. Lung sounds clear bilaterally. Suctioned for minimal clear thin secretions. Mouth care given per VAP protocol.\n\nGI-Abdomen soft, non distended with hypoative bowel sounds. H2 blocker for prophylaxis. OGT placed and to LCWS with bilious drainage.\n\nGU-Indwelling foley catheter with clear yellow uop in adequate amounts, no lyte repletion.\n\nENDO-RISS, no coverage required.\n\nID-No antibiotics, afebrile.\n\nINTEG-Right eye with abrasion extending to cheek, bacitracin applied.\n\n husband was driver in accident and remains at , he is aware of patients transfer to and has not yet hospital. No other family contacts overnight.\n\nPLAN-Serial HCT's, extubate once TLS cleared, provide emotional support to pt and family once .\n" }, { "category": "ECG", "chartdate": "2123-12-03 00:00:00.000", "description": "Report", "row_id": 219216, "text": "Sinus arrhythmia. Non-specific ST-T wave changes. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1008530, "text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumo\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p CT removal\n REASON FOR THIS EXAMINATION:\n pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to assess for pneumothorax.\n\n FINDINGS: In comparison with previous study, the chest tube has been removed.\n No evidence of pneumothorax. Endotracheal tube and nasogastric tube have also\n been removed. Some atelectatic changes seen at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-03-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1008443, "text": " 5:38 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal- will be\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal- will be in CVICU approx.\n 5:45 PM- please call first\n ______________________________________________________________________________\n WET READ: GWp WED 6:28 PM\n ETT 4.5cm from carina, Swan in place, OGT tip & side hole below diaphragm.\n Cerclage wires intact. Mild pulm congestion. Artifact mildly limits eval of\n mediastinum. GWilliams\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG.\n\n FINDINGS: Extensive artifacts make is extremely difficult to evaluate the\n upper portion of the lungs and adjacent monitoring devices. The endotracheal\n tube tip lies at least 4 cm above the carina. Right IJ catheter extends to\n the right pulmonary artery. Nasogastric tube extends to the lower body of the\n stomach, then coils back on itself so that the tip lies just below the\n cardioesophageal junction. Left chest tube is in place without definite\n pneumothorax.\n\n IMPRESSION: Standard appearance following cardiac surgery, though the image\n suffers from technical artifacts.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-03-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1008908, "text": " 10:06 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rule out effusion, infiltrate.\n\n CHEST, TWO VIEWS.\n\n The patient is status post sternotomy, with cardiomegaly and borderline\n ectatic, tortuous aorta. There is blunting of the costophrenic angles\n posteriorly consistent with small effusions or a small amount of pleural\n thickening. Minimal blunting is also seen laterally. There is linear\n atelectasis or scarring in the left greater than right mid zones. No CHF or\n focal infiltrate is identified. Probable atelectasis at left base as well.\n\n IMPRESSION: Cardiomegaly. Small bilateral effusions. Bilateral atelectasis.\n Probable atelectasis, but cannot exclude an early infiltrate at the left base.\n\n\n\n" }, { "category": "Echo", "chartdate": "2101-03-09 00:00:00.000", "description": "Report", "row_id": 64434, "text": "PATIENT/TEST INFORMATION:\nIndication: coronary artery disease\nWeight (lb): 240\nStatus: Inpatient\nDate/Time: at 17:39\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\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: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the\naortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: 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. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium/left atrial appendage or the\nbody of the right atrium/right atrial appendage. No atrial septal defect is\nseen by 2D or color Doppler. 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.\nThere are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm)\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 leaflets are mildly thickened. Physiologic mitral\nregurgitation is seen (within normal limits). There is no pericardial\neffusion. Dr. was notified in person of the results on Ms. at\n1pm\n\nPOST-BYPASS: Regional and global left ventricular systolic function are\nnormal. Thoracic aortic contour is intact. Minimal MR.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-03-08 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1008304, "text": " 4:59 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with cad\n REASON FOR THIS EXAMINATION:\n preop cabg\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coronary artery disease, preop CABG.\n\n COMPARISON: None.\n\n FINDINGS: PA and lateral views of the chest. The cardiac silhouette is\n enlarged with a left ventricular configuration. The aorta is tortuous. The\n lungs are clear. There is no pneumothorax or pleural effusion. The pulmonary\n vasculature is normal. The osseous structures are unremarkable.\n\n IMPRESSION: Cardiomegaly, without evidence of CHF or pneumonia.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-03-09 00:00:00.000", "description": "Report", "row_id": 1659594, "text": "Rec'd patient from OR. NSR, pacer sense and capture, ademand 60. ?peaked t waves, EKG to be done. Rec'd on no pressors, propofol at 30. Increased BP treated with increased propofol without result. Nitro started, patient with BP 130's systolic, Nitro titrated. Labs as noted. CO output low by thermodilution, improved by FICK with MVSAT 66. CT with minimal output. Insulin gtt up at 1unit.\nDaughter updated by RN, has not heard for surgery.\nPlan: Wean vent as tolerated. Maintain VS/ CO as needed.\n" }, { "category": "Nursing/other", "chartdate": "2101-03-10 00:00:00.000", "description": "Report", "row_id": 1659595, "text": "Neuro: pt sedated with propofol until around midnight when propofol weaned to off. pt awake following commands moving all extremities but sleepy.\nResp: pt remained vented overnight 2nd to sleepiness. Vent weaned to CPap with ips of 12 down to 5 with good abg's suctioned for scant amount of clear. RR on Cpap with ips of 5 is 16-20 with TV of 330-350. Pt ready for extubation on rounds.\nC/V: pt heart rate in the 70's sinus with borderline hemodynamics at begining of shift, PA numbers low.. pt required 2 l LR and pacer increased to 90 for part of shift. Hemodynamics improved with CI >2.5 after volume. Pedal pulses palpable by middle of night. Nitro tirated up to 2.25 mcg with SBP remaining abouve 140's Nipride added and tirtated up so nitro could be titrated off. pt presently on Nipride 0.8 mcg and nitro is off. BP well controlled with SBP in the 120's\nChest tubes draining 20cc/hr overnight no air leak seen.\nGI OGT draining clear fluid small amounts. Placement verified by ascultation.\nENdo: pt on insulin gtt tirtated to csru protocol. See flow sheet for rate\nGU: adequate urine output.\nSkin: Dsg intact no drainage. Criticaid applied to coccyx for protedtion.\nPlan: Extubate in am when staff available. OOB to chair. Start Lantus per CVICU protocol. Titrate nipride as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-03-10 00:00:00.000", "description": "Report", "row_id": 1659596, "text": "Resp Care: Pt continues on mechanical ventilation: PSV 5/5 50%. VE ~8.0LPM. Most recent ABG: 7.35/40/89/23/-3. LS clear bilaterally. Sxn'd for small amounts of thick white secretions. RSBI this am: 60. PLAN: extubate\n" }, { "category": "ECG", "chartdate": "2101-03-09 00:00:00.000", "description": "Report", "row_id": 132468, "text": "Sinus rhythm. Low normal voltage in the limb leads, low voltage in the\nprecordial leads. Left atrial abnormality. QS deflections in leads VI-V2\ncompatible with anteroseptal myocardial infarction. Significant Q waves in\nleads III and aVF compatible with inferior wall myocardial infarction. Compared\nto the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2101-03-08 00:00:00.000", "description": "Report", "row_id": 132469, "text": "Sinus rhythm. Prior anteroseptal myocardial infarction. Compared to the\nprevious tracing of no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2104-07-09 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 1027459, "text": " 9:44 AM\n MR W& W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: EPIDURAL ABSCESS\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with s/p drainage epidural abscess\n REASON FOR THIS EXAMINATION:\n ? interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR OF THE CERVICAL AND LUMBAR SPINE DATED \n\n COMPARISON: .\n\n INDICATION: 52-year-old male status post drainage of an epidural abscess.\n Questionable interval change.\n\n TECHNIQUE: Sagittal T1, sagittal T2, sagittal STIR, and axial gradient-echo\n images were obtained of the cervical spine. Large field of view thoracic\n spine imaging was obtained with sagittal T2-weighted images. Lumbar spine\n imaging includes sagittal T1, sagittal T2, sagittal STIR, and post-gadolinium\n axial and sagittal T1.\n\n CERVICAL SPINE FINDINGS: Post-surgical changes are seen in the cervical spine\n with allograft disc at C3-C4 and C4-C5. There is marked prevertebral soft\n tissue swelling with mixed signal intensity. There is also edema seen in C3,\n C4, and C5 vertebral bodies. Slight increased signal is seen in the dura just\n posterior to these vertebral bodies as well. From an imaging standpoint, it\n is difficult to differentiate between post-operative changes and residual\n infection. No spinal cord signal abnormality is identified.\n\n Large field of view imaging of the thoracic spine shows an acute kyphosis at\n T5-T6.\n\n LUMBAR SPINE FINDINGS: There is marked scoliosis of the lumbar spine with a\n leftward convex configuration. Endplate degenerative changes are seen in the\n lower lumbar spine. The conus ends at T12-L1.\n\n There is mixed signal intensity in the paraspinous soft tissues predominantly\n posterior to L3 and L4. Increased T2 signal is also seen in the right\n paraspinous musculature. There also appears to be a small rim-enhancing fluid\n collection measuring 1.5 x 1.8 x 1.2 cm in the AP, transverse, and\n craniocaudad dimensions respectively. This likely represents a small abscess\n in the right paraspinal musculature. There does not appear to be any\n intraspinal extension of the inflammatory change and abscess in the posterior\n paraspinous musculature.\n\n Degenerative changes are noted in the lumbar spine. These are most prominent\n at L4-L5 where scoliosis and spondylosis contributes to spinal stenosis.\n\n (Over)\n\n 9:44 AM\n MR W& W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: EPIDURAL ABSCESS\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Incidental note is made of a T2 hyperintense left renal cyst.\n\n IMPRESSION:\n 1. Marked prevertebral soft tissue swelling with mixed signal intensities.\n Post-operative changes and edema can have this appearance. From an imaging\n standpoint, it is difficult to rule out residual infection. Followup MR \n of the neck may be helpful to document resolution of these changes.\n 2. Small abscess in the right paraspinal musculature, posterior to L3 and L4\n as described above. There are associated inflammatory changes in the muscle,\n likely representing myositis.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-07-14 00:00:00.000", "description": "CT GUIDED NEEDLE PLACTMENT", "row_id": 1028482, "text": " 2:20 PM\n PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: Please drain right abscess in the right paraspinal musculatu\n Admitting Diagnosis: EPIDURAL ABSCESS\n ********************************* CPT Codes ********************************\n * PUNC ASP ABS HEM BUL CYST CT GUIDED NEEDLE PLACTMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man, IVDU with persistent fever up to 102 and cervical (drained)\n abcess and para-spinal lumbar abcess on day 7 of vancomycin (grew MRSA).\n REASON FOR THIS EXAMINATION:\n Please drain right abscess in the right paraspinal musculature; seen in prior\n CT. Send fluid for gram stain, culture (aerobic and anaerobic), fungal culture,\n AFB stain and AFB culture.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old male, IVDU with persistent fever up to 102 and cervical\n (drained) abscess and paraspinal lumbar abscess on day seven of vancomycin\n (grew MRSA). Please drain right abscess in the right paraspinal musculature.\n\n TECHNIQUE: After discussion of the risks and benefits of the procedure with\n the patient, written informed consent was obtained. A timeout procedure was\n performed using three patient identifiers.\n\n The preliminary contrast-enhanced CT scan of the lower thoracic and lumbar\n spine demonstrated subtle fat stranding (images 20 through 22, series 2) in\n the right paraspinal musculature at approximately the L2/3 level. This region\n was targeted for the CT-guided aspiration.\n\n The skin overlying the lower thoracic/upper lumbar spine was prepped and\n draped in the usual sterile fashion. 2% lidocaine was used for local\n anesthesia. Under CT fluoroscopic guidance, a 20-gauge spinal needle was\n guided into the region of fat stranding at the L2/L3 level in the right\n paraspinal musculature. Approximately 1 cc of blood-tinged purulent fluid was\n aspirated. This purulent material was sent to the laboratory for Gram stain,\n culture (aerobic and anaerobic), AFB culture and stain and fungal culture.\n\n The patient tolerated the procedure well without immediate post-procedure\n complication.\n\n Radiology attending, Dr. , was present and actively participated\n throughout the duration of the procedure.\n\n IMPRESSION: Successful aspiration of 1 cc of blood-tinged purulent fluid\n (approximately 1 cc). This sample was sent to the laboratory for\n microbiologic studies.\n\n (Over)\n\n 2:20 PM\n PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: Please drain right abscess in the right paraspinal musculatu\n Admitting Diagnosis: EPIDURAL ABSCESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2104-07-06 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 1026904, "text": " 10:16 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: evaluate for epidural abscess\n Admitting Diagnosis: EPIDURAL ABSCESS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with a 2 wekk history of neck and back pain, fever, presented\n to OSH and found to have disc space infection, vertebral osteomyelitis at C3-C4\n and C4-C5 with small epidural phlegmon and/or abscess superimposed on\n degenerative disc disease.\n REASON FOR THIS EXAMINATION:\n evaluate for epidural abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb SUN 3:06 PM\n Discitis and osteomyelitis from C3 through C5 with prevertebral phlegmon and\n abscesses. There is epidural phlegmon and a possible tiny epidural abscess at\n C4-C5 slightly to the left of midline measuring 6.5 mm. There is encasement\n of the cord by the epidural process with mild increased signal within the\n cord, which could represent compressive myelopathy.\n\n In the lumbar spine, there is abnormal signal within the lumbar vertebral\n bodies at L1 through L3, concerning for osteomyelitis. There is also right\n paraspinal muscle enhancement and possible abscess formation from L1 through\n L5 abutting the facet joints. There is epidural enhancement at L2-L3 on the\n right, without convincing evidence for an abscess. There is a possible left\n paravertebral abscess at T12-L1.\n\n Findings were discussed with Dr. at the time of attending\n interpretation.\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL, THORACIC, AND LUMBAR SPINE WITHOUT AND WITH GADOLINIUM\n\n HISTORY: Discitis, osteomyelitis.\n\n FINDINGS:\n\n Evaluation of the cervical spine demonstrates abnormal signal within the C3,\n C4, and C5 vertebral bodies and the intervening disc spaces. There is\n extensive prevertebral edema and phlegmon and a possible prevertebral abscess\n on the left at C4 measuring approximately 10 x 9 mm. There is epidural\n phlegmon from C2-C3 through C5-C6. There is a questionable small(6.5 mm)\n epidural abscess on the left at C4-C5. There is effacement of the anterior\n thecal sac, and the epidural enhancing tissue encases the cord. There is mild\n cord hyperintensity at C3-C4, which may represent sequelae of compressive\n myelopathy.\n\n Evaluation of the thoracic spine is limited due to severe scoliotic curvature\n to the right. No definite evidence for discitis, osteomyelitis is seen. There\n is a left-sided pleural fluid collection.\n (Over)\n\n 10:16 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: evaluate for epidural abscess\n Admitting Diagnosis: EPIDURAL ABSCESS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Evaluation of the lumbar spine demonstrates abnormal enhancement along the\n right facet joint from L1 through L5. There is extensive paraspinal\n enhancement in this locale.\n\n There is epidural enhancement, most prominent at L2-L3 on the right with also\n enhancement noted within the right foramen. No convincing evidence for an\n epidural abscess is seen. There is epidural enhancement within the thecal sac\n on the left at L5-S1.\n\n There is a questionable right paraspinal abscess at L3-L4 measuring\n approximately 1.3 x 2.4 cm. A questionable 14 x 9 mm abscess may also be\n present in the right paraspinal tissue at L2.There is abnormal enhancment in\n the L1-L3 vertebral bodies concerning for osteomyelitis. There is a left\n prevertebral abscess at T12- L1 level measuring approximately 1.5 cm in size.\n\n There is suggestion of a left loculated pleural fluid collection measuring 7.4\n mm. There is a large 3.8 x 4.7 cm left renal cyst.\n\n IMPRESSION:\n\n Discitis, osteomyelitis from C3 through C5 with extensive prevertebral\n phlegmon and abscess. Tiny focus of epidural abscess as well as the\n predominant epidural phlegmon in the cervical spine.\n\n Osteomyelitis in the lumbar spine, predominantly from L1 through L3. There is\n abnormal enhancement in the right paraspinal musculature abutting the facet\n joint from L1 through L5. There is a left prevertebral/paravertebral abscess\n at T12-L1. There is epidural enhancement at L2-L3 on the right, which appears\n continous with the paraspinal musculature enhancement. No convincing evidence\n for epidural abscess in the lumbar spine is seen. There is also prominent\n epidural enhancement within the left aspect of the canal at L5-S1.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2104-07-06 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 1026905, "text": ", E. NMED FA11 10:16 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: evaluate for epidural abscess\n Admitting Diagnosis: EPIDURAL ABSCESS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with a 2 wekk history of neck and back pain, fever, presented\n to OSH and found to have disc space infection, vertebral osteomyelitis at C3-C4\n and C4-C5 with small epidural phlegmon and/or abscess superimposed on\n degenerative disc disease.\n REASON FOR THIS EXAMINATION:\n evaluate for epidural abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Discitis and osteomyelitis from C3 through C5 with prevertebral phlegmon and\n abscesses. There is epidural phlegmon and a possible tiny epidural abscess at\n C4-C5 slightly to the left of midline measuring 6.5 mm. There is encasement\n of the cord by the epidural process with mild increased signal within the\n cord, which could represent compressive myelopathy.\n\n In the lumbar spine, there is abnormal signal within the lumbar vertebral\n bodies at L1 through L3, concerning for osteomyelitis. There is also right\n paraspinal muscle enhancement and possible abscess formation from L1 through\n L5 abutting the facet joints. There is epidural enhancement at L2-L3 on the\n right, without convincing evidence for an abscess. There is a possible left\n paravertebral abscess at T12-L1.\n\n Findings were discussed with Dr. at the time of attending\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2104-07-12 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1028144, "text": " 1:36 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: check placement of right picc line. measures 53 cm\n Admitting Diagnosis: EPIDURAL ABSCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n check placement of right picc line. measures 53 cm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SAT 2:21 PM\n Right PICC seen in the right atrium.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 13:46\n\n INDICATION: Right PICC line.\n\n COMPARISON: at 11:37.\n\n FINDINGS: Right PICC line is seen with its tip in the right atrium. There is\n no pneumothorax. Less prominence of the interstitial markings visualized on\n the current exam and there are no focal consolidations. Scoliosis of the\n spine is seen, convex to the right at the diaphragmatic level. Skin staples\n are seen projecting over the neck region.\n\n IMPRESSION: PICC line in the right atrium. Improved appearance of\n interstitial markings.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-07-12 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1028145, "text": ", NSURG FA11 1:36 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: check placement of right picc line. measures 53 cm\n Admitting Diagnosis: EPIDURAL ABSCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n check placement of right picc line. measures 53 cm\n ______________________________________________________________________________\n PFI REPORT\n Right PICC seen in the right atrium.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-07-10 00:00:00.000", "description": "Report", "row_id": 1643029, "text": "ADDENDUM\n\nPT APPEARING IN TRIGEMENY. DR NOTIFIED. NOT CONSISTENT. EKG OBTAINED. AM LABS WNL. WILL CONT TO MONITOR.\nPCA DOSE INCREASED FOR PAIN CONTROL.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-10 00:00:00.000", "description": "Report", "row_id": 1643030, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: PRIMARLY SPANISH SPEAKING ALTHOUGH PT ABLE TO COMMUNICATE SIMPLE THOUGHTS IN ENGLISH. ALERT, ORIENTED X3, MAE WITH EQUAL STRENGTH. PERRL. ASPEN COLLAR IN PLACE, NECK INCISION CLEAN AND DRY\nCV: T MAX 101/2= TEAM AWARE, HR 60-70 NSR WITH OCCASIONAL PVC'S. SBP 120-160.\nRESP: BS COARSE. PT COUGHING AND RAISING LARGE AMTS THICK TAN SECRETIONS, USING SUCTION, PT DOES INCENTIVE SPIROMETER WELL, SATS >94% ON ROOM AIR\nGI: ABD SOFT, +BS, TOL DIET WELL, IVF D/C'D\nGU: UO LOW THIS AM BUT HAVE INCREASED WITH PO INTAKE\nENDO: INSULIN GTT OFF, PT STARTED ON NPH AND SLIDING SCALE\nPAIN: DIFFICULT TO DETERMINE IF PT UNDERSTANDS CONCEPT OF PAIN RATING SCALE, HE APPEARS COMFORTABLE BUT WHEN ASKED STATES HIS PAIN IS . DILAUDID PCA D/ AND PT STARTED ON OXYCODONE PO Q4HRS AS NEEDED -\nACTIVITY: OOB TO CHAIR X2 WITH ASSISTANCE.\nA/P: CONT TO MONITOR HEMODYNAMICS, VIGOUROUS PULM TOILET, MONITOR BS CLOSELY AND ? RESUME PT'S HOME DOSE OF LANTUS, AWAITING BED ON FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-09 00:00:00.000", "description": "Report", "row_id": 1643025, "text": "resp care\nPt initially on psv12/peep5 and 40% with volumes of 400'scc and rr 32-36.BS slightly coarse.Suct for sml amts of thick yellow sput.Psv to 8 with good volumes /rr.During the course of the night pt became more tachypneic with rr again >35 with irregular breathing pattern.Bs worsened with increasing congestion and prolonged exp wheeze. Alb mdi started.Psv inc for a short time back to 12 but was back to 8 this am.Sats remained >96%.Suct this am for mod amts of thick yellow sput with copious oral secretions,creamy yellow nasal secretions. Weak cough/gag. RSBI done =83.Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-09 00:00:00.000", "description": "Report", "row_id": 1643026, "text": "Events: MRI Cspine/Lspine. Extubated\n\nNeuro: A&O x 3, follows commands, communicates needs. MAE with equal strength. Torodol and dilaudid PCA initiated for post-op pain. Pt states lower back pain \"is gone\". Aspen collar intact.\n\nCV: Sr/no ectopy, map>60\n\nPulm: 3L nc in place, 02 sat 98%. Lungs coarse throughout, pt expectorating large amounts of clear secretions. He is using IS to 1000cc/vol, coughing and deep breathing.\n\nGU: Uo>30cc/hr clear yellow\n\nGI: Abd obese, bs present, currently npo.\n\nEndo: Continues on insulin gtt to keep bs <150.\n\nSoc: No contact from family, pt states he lives with his older brother.\n\nP: q4hr neuro checks, notify team of any change. Continue anagesics, note response to same. Encourage pulm hygiene q1-2hrs. ?speech/swallow eval, advance diet as ordered and indicated, transition to home insulin regiman once diet is tolerated. Increase acitivity, consider transfer out of ICU in am. Will need pic line eval for long term IV antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-09 00:00:00.000", "description": "Report", "row_id": 1643027, "text": "Resp Care\nPt had MRI this morning without incident and was weaned and extuabted after with cook cath and fellow present. Pt had audible cuff leak and no stridor post, strong productive cough of mod amt thick clear secretions. pt currently on 3 l NC satting 99%.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-10 00:00:00.000", "description": "Report", "row_id": 1643028, "text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: PRIMARILY SPANISH SPEAKING. A&OX3. MAE, FOLLOWING COMMANDS & ASSISTING IN CARE. SPANISH INTERPRETER CALLED AT CHANGE OF SHIFT TO GO OVER PCA PUMP. PT APPEARED TO UNDERSTAND USING PUMP MORE APPROPRIATELY AND STATING BACK TO INTERPRETER HOW TO USE WITH NO ADDITIONAL QUESTIONS, HOWEVER OVER COURSE OF EVENING CONTINUED TO HIT PAIN BUTTON VERY FREQUENTLY. GIVEN PRN KETOROLAC FOR BREAKTHROUGH PAIN RATING ON SCALE WITH SMALL EFFECT, ? REINSTITUTE PRN FENTANYL >> WILL CONT TO MONITOR PAIN (APPEARS TO INCREASE WITH C/DB).\n\nRESP: LUNGS COARSE. SAT'S 97-99% 3L NC. STRONG PRODUCTIVE COUGH BRINGING UP CLEAR THICK SECRETIONS, USING YANKEUR. USING IS, VOLUMES TYPICALLY RANGING FROM 1000-1500.\n\nCV: LOW GRADE FEVER, TMAX 100.1. NSR HR 60-70 RARE PVCS NOTED. SBP 100-125.\n\nGI/GU: OBESE ABD, + BS. NO BM. DIET ADVANCED TO REGULAR, TOLERATING CLEARS WELL. FOLEY PATENT, >40CC CYU HOURLY.\n\nENDO: TITRATING INSULIN DRIP FOR GOAL FBS <150. FBS RANGING FROM 85-140.\n\nSKIN: NECK REMAINS W/STAPLES. SITE C/D, SCANT SER/SANG DRAINAGE NOTED.\n\nSOCIAL: NO CONTACT FROM FAMILY OR FRIENDS.\n\nPOC: PULM TOILET. MONITOR PAIN/COMFORT. INSULIN GTT. ASPEN COLLAR X1 MONTH. PICC IN FUTURE FOR ABX. INCREASE ACTIVITY AS TOL. ? TRANSFER IN AM. HO AWARE OF ABOVE, NOTIFY W/ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-07 00:00:00.000", "description": "Report", "row_id": 1643019, "text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS.\n\nNEURO: SEDATED ON PROPOFOL. AROUSES TO VOICE. CONSISTENTLY FOLLOWS COMMADS. PERRLA,BRISK. MAE WITH STRONG PURPOSEFUL MOVEMENT. C/O PAIN. MEDICATD WITH 50MCG OF FENTANYL WITH GOOD EFFECT.\n\nCARDIAC: NSR. HR: 80'S. NIBP: 96-107/56-66. +RADIAL, FEMORAL,POPITEAL,PT AND DP X2. CLS ON. SC HEPARIN.\n\nPULM: AC/40%/500/5 PEEP/R 14. ABG: 7.51/34/97/3/28, MD ENGLISH NOTIFIED, AND TV DECREASED TO 450. REPEAT ABG AT 200O. ATTEMPTEFD TO WEAN TO EXTUBATE TOADAY. PT RR HIGH 30'S-SEDATED FOR PAIN RR REMAINED MID-HIGH 30' MD BENDER PLAN TO EXTUBATE AM OF . LS: COASRE. SX FOR SM TO MODERATE AMTS OF THICK BLOODY SECRECTIONS.\n\nGI: NPO. OGT TO CLW SX WITH SM AMT OF BILIOUS DRAINGE. ABD:D,+BSX4,S,NT.\n\nGU: FOLEY WITH QS URINE.\n\nID: T-MAX: 101.9, 650 TLENOL GIVEN WITH GOOD EFFECT. BLD CULTURES X2 SENT.\n\nIVL'S: PIV'S X3 AND A-LINE SITES WNL'S AND DRESSINGS INTACTS.\n\nPSYCH/SOCIAL: NO FAMILY CONTACT.\n\nPLAN: Q 2 HOUR NEURO CHECKS. PAIN MANAGEMENT. MONITOR HEMODYNAMICS. AGGRESSIVE PULM HYGIENE. TITRATE VENT SUPPORT AS TOLERATED. SURVALLANCE LABS PRN. REPOSITION Q 2. AGGRESSIVE SKIN CARE. PROVIDE SUPPORTIVE CARE TO PT.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-08 00:00:00.000", "description": "Report", "row_id": 1643020, "text": "condition update\nd: pt sedated on propofol 20-30mcgs/kg/min, pt opens eyes to name and follows commands. pupils are equal and reactive to light. pt able to lift and fall bilateral legs and lift and hold bilateral arms. pt c/o pain and medicated with 50mcgs/kg/min of fentanyl with good relief. pt's aspen collar remains on and neck dressing is dry and intact.\ncardiac: pt min nsr rate 60-80. sbp 100-120/50.\nresp: pt on cmv breathing 26 over rate of 12. o2 sat 98% and see flowsheet for abg results. pt suctioned for thick white sputum breath sounds are clear to coarse and diminished in the bases. pt tried on cpap with pressure support and tolerated for a short time then became tachypnic to the high 30's. o2 sat remains 98%. pt placed back on cmv with am rsbi 123. pt to remain on cmv until rounds.\ngi: ogt to suction draining bilious drainage. abd soft distended with positive bowel sounds.\ngu: foley patent draining clear yellow urine. iv fluid d5ns at 80cc/hr.\nskin: neck dressing is dry and intact. no areas of breakdown noted.\na: assess for pain and medicate as needed. q2 neuro exam. tylenol for fever. monitor for culture results. ? need for picc line for long term antibiotics.\nr: fentanyl effective in relieving pain. no change in neuro status. pt remains on vanco awaIt culture results.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-07 00:00:00.000", "description": "Report", "row_id": 1643016, "text": "Resp Care\nPt received intubated with 7.5 ett @ 22, patent and secure. Placed on vent. (see carevuse flowsheet for settings). Abg drawn. Ett retaped. Weaned fio2. Suctioned for mod amt of blood-tinged secretions. Rsbi 77. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-07 00:00:00.000", "description": "Report", "row_id": 1643017, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT FROM OR ~ 2300 S/P C2-C4 ABCESS EVACUATION. PATIENT CURRENTLY ON PROPOFOL AND ABLE TO FOLLOW SIMPLE COMMANDS, MOVE ALL EXTREMITIES AND NOD \"YES/NO\" TO QUESTIONS. DISCUSSED WITH DR. (NSURG) Q2H NEURO CHECKS. ABLE TO LEAVE PROPOFOL ON DURING CHECKS IF PATIENT FOLLOWING COMMANDS AND APPROPRIATE (PATIENT SEEN BY NSURG, NO NEURO DEFICITS). NECK DRESSING DRY & INTACT, ASPEN COLLAR IN PLACE.\n PATIENT ON ASSIST CONTROL, TOLERATING OKAY. SEE RESP NOTE. FI02 DECREASED FROM 100% TO 60% AND PATIENT OXYGENATING OKAY. LUNG SOUNDS CLEAR, RESP RATE APPROX 20-24.\n ABDOMEN DISTENDED. OG TUBE PLACED WITH MODERATE AMOUNT BILIOUS OUTPUT. BLOOD GLUCOSE 250-300 DESPITE SQ INSULIN, WAITING FOR INSULIN GTT FROM PHARMACY. MAKING ADEQUATE HOURLY URINE.\n HEART RATE 70'S NORMAL SINUS. AFEBRILE. SBP 90-110. PLAN:\n? EXTUBATE TODAY. RESP THERAPY TO ATTEMPT CPAP + PS THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-07 00:00:00.000", "description": "Report", "row_id": 1643018, "text": "Respiratory Care:\nPt remains intubated. Were considering extubation but Temp up and RR\nto hi 30's on psv... THE trach tie is CUT under his left ear but seems secure at present there is a cook's Cath on top of the vent for extubation ? tomorrow; he was a difficult intubation. Back on CMV over noc. 40% 500 14 5 mv = 10\n\n" }, { "category": "Nursing/other", "chartdate": "2104-07-08 00:00:00.000", "description": "Report", "row_id": 1643021, "text": "Respiratory Care:\nAttempted to switch to CPAP mode; patient became tachypneic (rr>35). Now on A/C ventilatory support with no further changes in parameters noted. Latest abg results determined a mixed alkalemia with good oxygenation. Spiked a fever.\n\nRSBI = 123 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-08 00:00:00.000", "description": "Report", "row_id": 1643022, "text": "Respiratory Care:\nPt changed to PSV 12/5 @ 40% during rounds this AM..(by MD). he has been doing well with a RR in the 20's vs hi 30's to lo 40's. Sat = 99%\nsecretions have been less today; Rotated and re-taped the ETT this PM.\nNo other issues.\n" }, { "category": "Nursing/other", "chartdate": "2104-07-08 00:00:00.000", "description": "Report", "row_id": 1643023, "text": "NURSING PROGRESS NOTE\nNURSING PROGRESSS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS.\n\n52 Y/O MALE WITH PMH HTN,HYPERLIPIDEMIA,RESTRICTIVE LUNG DISEASE, DM,CRI,PVD S/P BILATERAL SFA STENTS,ICH IN AND HERNIA. ADMITTED ON FOR EPIDURAL CERVICAL ABSCESS OF C3-4 AND C4-C5 AND ANTERIOR DECMPRESSION OF ABSCESS PERFORMED. POD #2 FOR ANTERIOR ABSCESS DECOMPRESSION.\n\nPE:\n\nNEURO: SEDATED ON PROPOFOL. AROUSES TO VOICE. CONSISTENTLY FOLLOWS COMMANDS. PERRLA,BRISK. MAE WITH STRONG PURPOSEFUL MOVEMENT. RUE SLIGHTLY WEAKER THAN LUE. +GAG/COUGH. MEDICATED WITH IVP FENTANYL WITH GOOD EFFECT FOR PAIN.\n\nPULM: PSV/40%/. POX: 97-100%. RR: 15-24. LS: RHONCHI-COARSE WITH OCC EXP WHEEZES. SX FOR SM-MODERATE AMTS OF THICK BLODDY SECRECTIONS. MDI'S DISCUSSED-ON HOLD.\n\nCARDIAC: SB-NSR. HR: 58-80. ABP: 104-135/55-85. +RADIAL, FEMORAL, POPITEAL,PT AND DP X2. CSL ON. SC HEPARIN.\n\nGI: TF'S STARTED. ABD: D,+BSX4,S,NT. NO BM.\n\nGU: FOLEY WITH QS URINE. HUO: 50-100.\n\nENDO: CONTINUES ON INSULIN GTT. FS: 95-176.\n\nINTEG: SKIN WDI.\n\nIVL'S: PIV'S X2 SITES WNL'S AND DRESSINGS CDI. DISCUSSED PLACING PICC-LINE. PT HOLD.\n\nPSYCH/SOCIAL: NO FAMILY CONTACT.\n\nPLAN: Q2 HOUR NEURO CHECKS. PAIN MANAGEMENT. MONITOR HEMODYNAMICS. AGGRESSVIE PULM HYGIENE. TITRATE VENT SUPPORT AS TOLERATED. READDRESS EXTUBATION ON . SURVAILLANCE LABS PRN. AGGRESSIVE SKIN CARE. REPOSITION Q 2. ADVANCE TF'S AS TOLERATED. PROVIDE SUPPORTIVE CARE TO PT AND FAMILY.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-07-09 00:00:00.000", "description": "Report", "row_id": 1643024, "text": "SICU NPN\nNeuro: Arousable by voice while on propofol.MAE strongly. Nods appropriately to commands. Weak gag, + cough. Pain to neck, medicated with Dilaudid, good effect. Remains on Cspine precautions.\n\nCardio: SR in 60s, occasional PVCs. BP stable (MAP > 60). Decreases while sleeping.\n\nPulm: Tachypneic on CPAP, abdominal breathing, course breath sounds with exp wheezes. Resp tx given, PS increased to 12. Propofol ggt increased. Tachypnea improved. Copious oral and ETT secretions. PS decreased this am with RISB 82. Gag impaired, no cuff leak noted.\n\nGI: Abd soft, obesely distended. No pain noted. BS x 4 hypoactive. TF off at 4 in prep for possible extubation. Tolerated TF well. No BM.\n\nGU: Foley draining clear yellow urine. Body balance approx +400 at midnight.\n\nHeme: stable.\n\nID: Tmax 100 oral. WBC trending down. Vanco ordered.\n\nSkin: Intact. Ant neck incision CDI. Collar care done.\n\nSocial: No family contact overnight.\n\nA: Neuro status intact. Pulm status worsened overnight. Improved pain control with Dilaudid.\n\nPlan: Monitor respiratory status closely. Continue pulm toileting. CXR this am. Hold off on extubation? Pt difficult intubation. need Anesthesia present if extubating. Continue to monitor neuro status, pain control.\n\n\n" }, { "category": "Echo", "chartdate": "2104-07-07 00:00:00.000", "description": "Report", "row_id": 87720, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. ?endocarditis.\nHeight: (in) 70\nWeight (lb): 350\nBSA (m2): 2.65 m2\nBP (mm Hg): 93/58\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 11:55\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 and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild global LV\nhypokinesis. Estimated cardiac index is borderline low (2.0-2.5L/min/m2). TDI\nE/e' < 8, suggesting normal PCWP (<12mmHg). 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. Normal PA\nsystolic 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 apical views. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - poor\nsuprasternal views. Suboptimal image quality - body habitus. Suboptimal image\nquality - ventilator.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. There is mild global left\nventricular hypokinesis (LVEF = 40-45 %). The estimated cardiac index is\nborderline low (2.1L/min/m2). Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). 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. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with mild global left\nventricular hypokinesis c/w diffuse process (toxin, metabolic etc. cannot\nexclude, but multivessel CAD less likely). No valvular pathology or pathologic\nflow identified.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2104-07-10 00:00:00.000", "description": "Report", "row_id": 223559, "text": "Sinus rhythm\nFrequent premature ventricular contractions\nLong QTc interval\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Echo", "chartdate": "2112-10-31 00:00:00.000", "description": "Report", "row_id": 94407, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 71\nWeight (lb): 220\nBSA (m2): 2.20 m2\nBP (mm Hg): 135/69\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 10:56\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Good RAA ejection velocity (>20cm/s). No ASD\nby 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. No atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: Trivial/physiologic 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 monitored by a nurse e throughout the procedure. The patient was monitored by a nurse e throughout the procedure. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications. Echocardiographic results were reviewed by\ntelephone with the houseofficer caring for the patient. MD caring for the\npatient was notified of the echocardiographic results by e-mail.\nDr. was notified by page on at 11 am.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque to 45 cm from the incisors. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. No masses or vegetations are\nseen on the aortic valve. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. No mass or\nvegetation is seen on the mitral valve. No vegetation/mass is seen on the\npulmonic valve. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: No valvular pathology or pathologic flow identified.\n\n\n" }, { "category": "Echo", "chartdate": "2112-10-28 00:00:00.000", "description": "Report", "row_id": 94408, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. MRSA\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 130/72\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 11:34\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: No masses or vegetations on aortic valve. No AS. No AR.\n\nMITRAL VALVE: No mass or vegetation on mitral valve. Trivial MR.\n\nTRICUSPID VALVE: No mass or vegetation on tricuspid valve. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. No masses or vegetations are seen on the aortic\nvalve. There is no aortic valve stenosis. No aortic regurgitation is seen. No\nmass or vegetation is seen on the mitral valve. Trivial mitral regurgitation\nis seen. There is mild pulmonary artery systolic hypertension. No\nvegetation/mass is seen on the pulmonic valve. There is a small pericardial\neffusion.\n\nIMPRESSION: No vegetations or clinically-significant regurgitant valvular\ndisease seen (good-quality study). Normal global and regional biventricular\nsystolic function. Small pericardial effusion. In presence of high clinical\nsuspicion, absence of vegetations on transthoracic echocardiogram does not\nexclude endocarditis.\n\n\n" }, { "category": "Echo", "chartdate": "2112-10-25 00:00:00.000", "description": "Report", "row_id": 94409, "text": "PATIENT/TEST INFORMATION:\nIndication: FEVER, SEPTIC EMBOLI OF UNKNOWN ORIGIN\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 156/75\nHR (bpm): 112\nStatus: Inpatient\nDate/Time: at 15:25\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: Moderate symmetric LVH. Normal LV cavity size. Hyperdynamic\nLVEF >75%. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). Mild resting LVOT\ngradient.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The right atrium is moderately dilated. There is\nmoderate symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\nTissue Doppler imaging suggests a normal left ventricular filling pressure\n(PCWP<12mmHg). There is a mild resting left ventricular outflow tract\nobstruction. The aortic valve leaflets (3) are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Physiologic mitral regurgitation is seen\n(within normal limits). The tricuspid valve leaflets are mildly thickened.\nThere is moderate pulmonary artery systolic hypertension. There is a very\nsmall pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\n\n" }, { "category": "Radiology", "chartdate": "2112-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214044, "text": " 3:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with septic pulmonary nodules\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Septic pulmonary nodules.\n\n FINDINGS: In comparison with the study of , there are lower lung volumes.\n The previously described ill-defined nodular opacities appear more confluent,\n probably related to the lower lung volumes. Hazy opacification suggests\n pleural effusions and there is increasing retrocardiac opacification.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-10-26 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1214049, "text": " 4:27 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: rule out PE\n Admitting Diagnosis: ENDOCARDITIS\n Field of view: 37 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man tachycardic, increasing O2 requirement, large a-A gradient\n REASON FOR THIS EXAMINATION:\n rule out PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 5:14 AM\n No pulmonary embolism. Progressive right and left lower lobe atelectasis with\n increase in right, now moderate, non-hemorrhagic pleural effusion. Unchanged\n multiple bilateral nodules and opacities consistent with septic emboli.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia, increasing oxygen requirement and large A-a\n gradient. Evaluate for pulmonary embolism.\n\n CTA CHEST: MDCT imaging was performed from the thoracic inlet to the upper\n abdomen after the uneventful intravenous administration of 100 cc of Optiray.\n Sagittal, coronal, and oblique reformatted images were performed.\n\n COMPARISON: CT chest and outside hospital CT abdomen , .\n\n FINDINGS: Contrast opacification of the pulmonary arterial system is somewhat\n suboptimal, but no pulmonary embolism is present in the main, or segmental\n pulmonary arteries. Evaluation of more distal vessels is limited by poor\n bolus opacification and atelectasis. Small-to-moderate bilateral pleural\n effusions, right greater than left, are present which are stable to slightly\n increased since the most recent examination. Particularly in the right mid\n lung (4:59) and also in the left lower lobe are areas of lower attenuation\n within atelectatic lung that could be due to pneumonia. Similar to the prior\n study are multiple bilateral pulmonary nodules in both the upper, and lower\n lobes and in the right middle lobe, findings compatible with septic emboli.\n At the lung bases (4:82) are wedge shaped peripheral areas of relative lucency\n within atelectatic lung. These findings appear similar to the study, but were better visualized on the study where one\n can appreciate wedge shaped opacities with heterogeneous central lucency.\n These were better appreciated on the prior abdominal study since atelectasis\n and effusions had not yet developed. No pneumothorax is present. The heart\n and great vessels appear normal. Numerous mediastinal lymph nodes are\n present, including a right paratracheal lymph node measuring 13 mm (4:25). An\n aortopulmonary window lymph node measures 9 mm (4:34).\n\n Although not tailored for subdiaphragmatic evaluation, the upper abdomen\n appears unchanged. A hypodensity within the posterior spleen is unchanged.\n\n BONE WINDOWS:\n\n (Over)\n\n 4:27 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: rule out PE\n Admitting Diagnosis: ENDOCARDITIS\n Field of view: 37 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n No suspicious bone lesions are present.\n\n IMPRESSION:\n\n 1. No pulmonary embolism within the limitations of the study.\n\n 2. Numerous pulmonary nodules compatible with septic emboli. Bilateral lower\n lobe peripheral heterogenous opacities are now largely obscured by atelectasis\n are indeterminate but could also be due to septic emboli with possible\n infarction.\n\n 3. Small-to-moderate bilateral pleural effusions, increased from the study\n one day prior.\n\n 4. Regions of low attenuation within bilateral atelectasis, concerning for\n pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2112-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214360, "text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change of consolidation\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with MRSA bacteremia and multifocal pneumonia\n REASON FOR THIS EXAMINATION:\n Evaluate interval change of consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA bacteremia and multifocal pneumonia, evaluate for change.\n\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiographs from , , and\n .\n\n FINDINGS: Since the and examinations, there has only\n been slight increased opacification of the right hemithorax. Multifocal\n opacities in the left hemithorax appear stable. Left basilar atelectasis is\n stable, but left sided effusions appear larger. No pneumothorax is present.\n The cardiac silhouette appears enlarged, stable.\n\n IMPRESSION:\n\n Interval progression in bilateral effusions and consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2112-11-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1215020, "text": " 11:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: L picc 54cm \n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with new picc\n REASON FOR THIS EXAMINATION:\n L picc 54cm \n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb WED 2:36 PM\n No change in the large right anteriorly loculated pleural effusion which. The\n stability of this effusion may indicate that the Pleurex catheter may not be\n in communication with it.\n PFI VERSION #1 TXPb WED 1:32 PM\n PFI:\n\n 1. New left PICC with the tip at least at the estimated location of the\n cavoatrial junction but possibly 1-2 cm beyond this. No evidence of\n procedural complication.\n\n 2. Possible persistent right loculated pleural effusion. Followup with\n conventional PA and lateral radiograph is recommended when clinically\n feasible.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC positioning.\n\n COMPARISONS: Chest radiographs from to .\n\n UPRIGHT AP VIEW OF THE CHEST:\n\n The new left PICC can be easily followed to the mid SVC, at which point the\n wire is no longer seen. Beyond this point, the catheter seems to continue\n until at least to the estimated location of the superior cavoatrial junction.\n Further extension of the catheter tip may be missed due to cardiac motion\n artifact.\n\n There is homogeneous opacification of the right lobe indicating persistence of\n a right loculated effusion which is stable from and decreased from\n . There is no left pleural effusion. The well-circumscribed focal\n opacities in the right middle lung and left apex are still present, but not as\n well circumscribed. Otherwise, the lungs are clear. There is stable moderate\n cardiomegaly. The hilar and mediastinal contours are normal. There is no\n pneumothorax.\n\n IMPRESSION:\n\n 1. New left PICC with the tip at least at the estimated location of the\n cavoatrial junction but possibly 1-2 cm beyond this. No evidence of\n procedural complication.\n (Over)\n\n 11:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: L picc 54cm \n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Possible persistent right loculated pleural effusion. Followup with\n conventional PA and lateral radiograph is recommended when clinically\n feasible.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-11-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1215021, "text": "1. New left PICC with the tip at least at the estimated location of the\n cavoatrial junction but possibly 1-2 cm beyond this. No evidence of\n procedural complication.\n\n 2. Possible persistent right loculated pleural effusion. Followup with\n conventional PA and lateral radiograph is recommended when clinically\n feasible. Page: 3\n\n , M 28 () \n , J. MED CC7A 11:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: L picc 54cm \n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with new picc\n REASON FOR THIS EXAMINATION:\n L picc 54cm \n ______________________________________________________________________________\n PFI REPORT\n No change in the large right anteriorly loculated pleural effusion which. The\n stability of this effusion may indicate that the Pleurex catheter may not be\n in communication with it.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214206, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bacteremia, septic pulmonary emboli\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia, septic pulmonary emboli. Evaluate for change.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiographs from , , and .\n\n FINDINGS: There appeared to be progressive opacification of the right\n hemithorax, likely due to layering pleural effusion. An large opacity in the\n left upper lobe has increased in size and conspicuity as have numerous\n additional bilateral peripheral opacities. Increased retrocardiac\n consolidation has occurred. A left-sided effusion is likely present and may\n be small. No pneumothorax is present. The cardiac silhouette is largely\n obscured.\n\n IMPRESSION:\n 1. Progressive opacification of the right hemithorax due to layering\n effusion.\n 2. Increased left upper lobe opacity and consolidation. Increased size of\n numerous bilateral septic emboli.\n\n" }, { "category": "Radiology", "chartdate": "2112-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214520, "text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with multilobar pneumonia\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM\n\n CLINICAL INDICATION: 28-year-old with multilobar pneumonia, evaluate for\n interval change.\n\n Comparison is made to the patient's prior study of at 4:52.\n\n Single portable AP upright chest film on at 5 a.m. is submitted.\n\n IMPRESSION:\n\n Persistent low lung volumes with patchy bilateral airspace opacities with\n slight interval improvement at the left base. There are persistent bilateral\n pleural effusions, which at the right base may be somewhat loculated as there\n is a more rounded appearance on the current examination. The heart appears\n enlarged, but is unchanged and may reflect cardiomegaly and less likely\n pericardial effusion when correlated with a CT of . No pneumothorax.\n No evidence of pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-10-25 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1213905, "text": " 9:40 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Please evaluate pulmonary nodules\n Admitting Diagnosis: ENDOCARDITIS\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bacteremia, ?endocarditis\n REASON FOR THIS EXAMINATION:\n Please evaluate pulmonary nodules\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia and question of endocarditis. Pulmonary nodules.\n\n CT CHEST: MDCT imaging was performed from the thoracic inlet to the upper\n abdomen after the uneventful intravenous administration of 75 cc of Optiray.\n Axial 5- and 1.25-mm series were displayed. Sagittal and coronal reformats\n were performed.\n\n COMPARISON: Chest radiographs from and and\n CT abdomen and pelvis from .\n\n FINDINGS: Numerous bilateral pulmonary nodules of varying sizes ranging from\n 2mm to 1.7cm include round, solid nodules, ground glass lesions with dense\n borders (particularly in the right lower lobe, 2:43, 36, 37), and triangular\n lesions that sit on the pleural surface. Since the prior examination, new\n small bilateral pleural effusions and atelectasis have developed, larger on\n the right. Secretions are present in the left mainstem bronchus. No\n pneumothorax is present. The heart is top normal in size. No pericardial\n effusion is present. Several mediastinal and hilar lymph nodes are present,\n but these are not pathologically enlarged with the largest left paratracheal\n lymph node measuring up to 8 mm, and a conglomeration of subcarinal nodes\n measures up to 9 mm. No enlarged lymph nodes are present within the axilla.\n The lobes of the thyroid appear normal.\n\n Although not tailored for subdiaphragmatic evaluation, in the upper abdomen is\n a low-attenuation lesion in the posterior spleen, unchanged. A cyst in the\n right kidney measures 1.4 cm. Layering hyperdense material in the gallbladder\n could be due to vicarious excretion of contrast.\n\n BONE WINDOWS: No suspicious bone lesions are present.\n\n IMPRESSION:\n\n 1. Numerous bilateral pulmonary nodules some solid and round, some with dense\n perimeters and low density centers, and others triangular and peripheral, all\n concerning for septic emboli, infarcts, and disseminated infection.\n\n 2. New bibasilar atelectasis with bilateral effusions, right greater than\n left, which are small-to-moderate in size.\n\n 3. Secretions in the left main stem bronchus could predispose the patient to\n (Over)\n\n 9:40 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Please evaluate pulmonary nodules\n Admitting Diagnosis: ENDOCARDITIS\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aspiration.\n\n Findings were discussed via telephone with Dr. at 2:05 p.m. on\n .\n\n" }, { "category": "Radiology", "chartdate": "2112-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1213852, "text": " 8:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with ? septic emboli, fever\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, possible septic emboli.\n\n COMPARISON: None.\n\n PORTABLE UPRIGHT AP VIEW OF THE CHEST: There are low lung volumes. The heart\n size is borderline enlarged. The mediastinal contours are normal. There is\n crowding of bronchovascular structures. Patchy ill-defined nodular opacities\n are noted in the lung bases, as well as scattered within the upper lung\n fields bilaterally. A possible small right pleural effusion is noted. No\n pneumothorax is present. Surgical anchors are noted within the left shoulder.\n\n IMPRESSION: Ill-defined nodular opacities primarily within the lung bases.\n Findings are concerning for infectious process such as septic emboli, and a CT\n can be obtained for further evaluation.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2112-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214650, "text": " 4:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: progress of pleural effusion? worsening septic emboli?\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with MRSA bacteremia and known pulmonary septic emboli and\n question loculated pleural effusion.\n REASON FOR THIS EXAMINATION:\n progress of pleural effusion? worsening septic emboli?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST FILM AT 1607\n\n CLINICAL INDICATION: 28-year-old with MRSA bacteremia and known pulmonary\n septic emboli, question loculated pleural effusion, question progression,\n question worsening emboli.\n\n Comparison to at 4 a.m.\n\n A single portable upright chest film dated at 1607 is submitted.\n\n IMPRESSION:\n\n 1. Lung volumes remain low. There is more focal patchy nodular opacity at\n the left apex as well as in the right upper to mid lung which appears somewhat\n cavitary and may reflect known septic emboli which are now radiographically\n visible. More focal patchy opacity at the right lung base is also present and\n could represent a combination of compressive atelectasis, pneumonia and/or\n evolving septic embolic areas. The more rounded appearance to the right\n costophrenic angle is slightly less apparent on the current examination but\n still could represent loculated pleural fluid. The heart remains enlarged but\n unchanged which may reflect cardiomegaly or pericardial effusion. Interval\n improvement in aeration at the left lung base with no definite left pleural\n effusion identified on the current examination. Stable mediastinal contours.\n No evidence of pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2112-10-26 00:00:00.000", "description": "L US EXTREMITY NONVASCULAR LEFT", "row_id": 1214071, "text": " 8:41 AM\n US EXTREMITY NONVASCULAR LEFT Clip # \n Reason: please assess for infectious process, abcess\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with indurated area of left anterior shin in setting of scrotal\n abcess\n REASON FOR THIS EXAMINATION:\n please assess for infectious process, abcess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Indurated area of left anterior shin in setting of scrotal\n abscess. Please assess for infectious process or abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: Nonvascular lower extremity ultrasound.\n\n FINDINGS: Targeted son imaging was performed in the region of\n clinical concern anterior to the left shin. In the region of interest, a\n hypoechoic collection is seen, which is somewhat serpiginous and lobulated in\n configuration and measures 6.1 x 1.1 cm. A small amount of flow is seen about\n the periphery of this structure likely representing an adjacent subcutaneous\n vessel. There is edema of the adjacent subcutaneous fat and skin thickening.\n\n IMPRESSION: Serpiginous-appearing hypoechoic structure left anterior shin,\n possibly representing a fluid collection or alternatively superficial\n thrombophlebitis of a markedly distended venous structure. Clinical\n correlation is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1213891, "text": " 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for acute process\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with sepsis and acute desat/tachycardia\n REASON FOR THIS EXAMINATION:\n Please eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with sepsis and tachycardia.\n\n COMPARISON: Chest radiograph, and CT of the abdomen, , , exam performed at an outside hospital and scanned into PACS for\n review.\n\n PORTABLE UPRIGHT AP CHEST: Again seen are numerous ill-defined nodular\n opacities, worst at the lung bases, particularly the right costophrenic angle.\n A few nodular densities are seen in the upper lung zones as well. Given the\n reported clinical history of sepsis, this could represent septic\n emboli/multifocal pneumonia. There is increasing right pleural effusion.\n There is no pneumothorax. Lung volumes remain low, exaggerating the heart\n size, which is likely top normal. Visualized bones are unremarkable. There\n is no free air seen in the upper abdomen.\n\n IMPRESSION: Interval worsening of basilar predominant ill-defined nodular\n densities. Given the history of sepsis, these are concerning for septic\n emboli/multifocal pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2112-10-30 00:00:00.000", "description": "Report", "row_id": 251024, "text": "Normal sinus rhythm. RSR' pattern in lead V1. Compared to the previous tracing\nof the patient's heart rate has decreased from 134 to 91. No other\ndiagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2112-10-25 00:00:00.000", "description": "Report", "row_id": 251025, "text": "Sinus tachycardia. RSR' pattern in leads V1-V2. Poor R wave progression.\nLeftward axis. Compared to the previous tracing of no diagnostic\ninterval change.\n\n" }, { "category": "ECG", "chartdate": "2112-10-24 00:00:00.000", "description": "Report", "row_id": 251026, "text": "Sinus tachycardia. Left axis deviation. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2168-08-20 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1205600, "text": " 1:59 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: H/O PE EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with newly diagnosed Pe on OSH CTA\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: PBec SAT 10:30 PM\n 1. RLE: occlusive thrmobus in R CFv at level of confluence with GSV, extends\n throughout RLE into calf veins, though minimal flow noted at level of right\n popliteal vein.\n 2. LLE: chonic non-occlusive thrombus in left popliteal vein. PBishop\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Newly diagnosed pulmonary embolism at outside hospital CTA.\n Please evaluate for deep vein thrombosis.\n\n COMPARISON: Comparison is made to bilateral lower extremity ultrasound\n performed .\n\n TECHNIQUE AND FINDINGS: Grayscale and Doppler son was performed of the\n bilateral common femoral, superficial femoral, popliteal, peroneal and\n posterior tibial veins.\n\n In right lower extremity, there is an occlusive thrombus identified at the\n level of the confluence of the greater saphenous and right common femoral\n vein. Thrombus is partially occlusive within the greater saphenous and\n completely occlusive within the right common femoral vein. Occlusive right\n common femoral vein thrombus in is noted to extend inferiorly into the right\n posterior tibial and peroneal veins, though minimal flow is noted within the\n popliteal vein.\n\n In the left lower extremity, there is normal compressibility, flow and\n augmentation noted throughout the left common femoral and superficial femoral\n veins. At the level of the left popliteal vein, the vein is only partially\n compressible with peripheralization of remaining vascular flow, suggesting a\n chronic nonocclusive thrombus.\n\n IMPRESSION:\n 1. In right lower extremity, occlusive thrombus extending from right calf\n veins to the common femoral vein at the level of the greater saphenous vein,\n though minimal surrounding flow is noted in the right popliteal vein.\n 2. Chronic partially occlusive thrombus within the left popliteal vein.\n\n" }, { "category": "Radiology", "chartdate": "2168-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1205524, "text": " 6:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ICU admission, chest imaging not included in transfer\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with new transferred from OSH\n REASON FOR THIS EXAMINATION:\n ICU admission, chest imaging not included in transfer\n ______________________________________________________________________________\n WET READ: SJBj FRI 10:06 PM\n Low lung volumes, no consolidation, effusion or pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Transferred from outside hospital ICU, needs chest x-ray.\n\n FINDINGS: There are no old films available for comparison. The lung volumes\n are slightly low. There is a patchy area of volume loss at the left base\n which partially obscures the left hemidiaphragm that could represent small\n area of infiltrate versus volume loss. Otherwise, the lungs are clear. The\n heart is upper limits normal in size. There is no effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-19 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1205479, "text": " 1:10 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for cholecystitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with GB wall thickening on OSH CT scan today\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis\n ______________________________________________________________________________\n WET READ: MXAk FRI 1:59 PM\n There is mild gallbladder distention with gallbladder wall edema. There is\n however no evidence of stones, sludge, or intra or extrahepatic ductal\n dilatation. There is also a negative sign. These findings are\n nonspecific but if clinical suspicion for acalculous cholecystitis is high,\n MRI is the recommended study of choice.\n\n There is also a 1.7 x 1.5 x 1.4 cm hyperechoic structure in the liver which\n may be representative of a hemangioma. However, given the patient's history,\n an MRI is recommended for further evaluation.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with gallbladder wall thickening on outside\n CT with a history of pulmonary emboli and colon cancer.\n\n COMPARISON: None available.\n\n FINDINGS:\n\n The liver is normal in echotexture. There is a 2.7 x 1.7 x 1.8 cm anaechoic\n structure with a few incomplete internal septations in the left lobe of liver\n consistent with a septated liver cyst. Additionally, there is a 1.5 x 1.4 x\n 1.7 cm echogenic lesion in the right lobe of the liver with no evidence of\n internal vascularity suggestive of a hemangioma; however, a metastatic focus\n cannot be completely excluded.\n\n Otherwise, there is no intra- or extra-hepatic ductal dilatation with the\n common bile duct measuring 6 mm. The main portal vein is patent with\n hepatopetal flow.\n\n There is mild gallbladder distention with evidence of gallbladder wall edema.\n There is, however, no evidence of stones or sludge. No pericholecystic fluid.\n A son sign was negative, though the patient states he had\n been receiving pain medications.\n\n No free fluid is noted throughout the abdomen. The visualized portion of the\n pancreas are normal; however, portions of the pancreatic body and tail are\n obscured by gas, not seen. The spleen is normal measuring 11.3 cm. Bilateral\n kidneys are normal with no evidence of hydronephrosis or stones. The left\n kidney measuring 11.3 cm and the right kidney measuring 11.8 cm.\n\n IMPRESSION:\n\n (Over)\n\n 1:10 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Mild gallbladder distention and gallbladder wall edema without stones or\n sludge. These findings are nonspecific and may be related to third spacing or\n possible hepatitis. Acute acalculous cholecystitis is considered unlikely,\n however, if clinical suspicion for acalculous cholecystitis is high, a HIDA\n scan may be obtained for further evaluation.\n\n 2. 1.5 x 1.4 x 1.7 cm echogenic lesion in the right lobe of the liver, likely\n a hemangioma; however, due to patient's history of colon cancer, a metastatic\n lesion cannot be fully excluded. As a result, MRI is recommended for further\n evaluation.\n\n 3. Septated cyst visualized in the left lobe of the liver.\n\n" }, { "category": "Echo", "chartdate": "2168-08-20 00:00:00.000", "description": "Report", "row_id": 92390, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function.\nHeight: (in) 69\nWeight (lb): 191\nBSA (m2): 2.03 m2\nBP (mm Hg): 96/58\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 10:32\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 IVC diameter (>2.1cm) with <50%\ndecrease with sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, 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. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Late systolic\nMR jet. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The estimated\nright atrial pressure is >=15 mmHg. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The right\nventricular cavity is moderately dilated with moderate global free wall\nhypokinesis. Apical function is preserved ( sign). There is\nabnormal septal motion/position consistent with right ventricular\npressure/volume overload. The diameters of aorta at the sinus, ascending and\narch levels are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is mild posterior leaflet systolic\nA late systolic jet of mild (1+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis.\nModerate pulmonary artery systolic hypertension. Mild mitral valve prolapse\nwith mild mitral regurgitation.\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. Dr. \nwas notified by telephone on XX at XX.\n\n\n" }, { "category": "ECG", "chartdate": "2168-08-21 00:00:00.000", "description": "Report", "row_id": 255087, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2168-08-19 00:00:00.000", "description": "Report", "row_id": 255088, "text": "Sinus tachycardia. Possible old anterior myocardial infarction. Possible\nold inferior myocardial infarction. Left axis deviation. Compared to the\nprevious tracing of inferior myocardial infarction pattern is new.\nPrecordial ST-T wave changes are now present.\n\n" } ]

[ { "category": "ECG", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 108101, "text": "Sinus rhythm, atrial premature complexes, left atrial abnormality\nMarked left axis deviation\nRBBB with left anterior fascicular block\nInferior infarct - age undetermined\nConsider anterior myocardial infarction\nLateral T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2120-11-23 00:00:00.000", "description": "Report", "row_id": 108056, "text": "Sinus rhythm with atrial premature beat, left atrial abnormality\nLeft axis deviation\nRBBB with left anterior fascicular block\nConsider inferior infarct - age undetermined\nPossible anterior infarct - age undetermined\nLateral ST-T changes are nonspecific\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 108057, "text": "Sinus arrhythmia with 1st degree A-V block, consider type l second degree AV\nblock or bloced atrial premature complexes\nLeft atrial abnormality\nLeft axis deviation\nRBBB with left anterior fascicular block\nInferior infarct - age undetermined\nPossible anterior infarct - age undetermined\nLateral T wave changes are nonspecific\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 108053, "text": "Sinus tachycardia with borderline 1st degree A-V block\nPossible left atrial abnormality\nLeft axis deviation\nRBBB with left anterior fascicular block\nProbable anterior infarct - age undetermined\nConsider inferior infarct - age undetermined\nBorderline low QRS voltages in precordial leads\nSince previous tracing, Q waves in lead V3 more apparent\n\n" }, { "category": "ECG", "chartdate": "2120-11-23 00:00:00.000", "description": "Report", "row_id": 108054, "text": "*** CONSIDER ACUTE ST ELEVATION MI ***\nSinus rhythm long P-R interval consider type l second degree AV block or\nblocked atrial premature complexes, left atrial abnormality\nMarked left axis deviation\nRBBB with left anterior fascicular block\nQT interval prolonged for rate\nConsider inferior infarct - age undetermined\nSeptal ST elevation, CONSIDER ACUTE INFARCT\nLateral ST-T changes may be due to myocardial ischemia, intraventricular\nconduction delay\nSince previous tracing, Q in lead V1 more apparent\n\n" }, { "category": "ECG", "chartdate": "2120-11-23 00:00:00.000", "description": "Report", "row_id": 108055, "text": "*** CONSIDER ACUTE ST ELEVATION MI ***\nSinus rhythm with long P-R interval, consider type l second degree AV block or\nblocked atrial premature complexes, left atrial abnormality\nMarked left axis deviation\nRBBB with left anterior fascicular block\nQT interval prolonged for rate\nConsider inferior infarct - age undetermined\nSeptal ST elevation, CONSIDER ACUTE INFARCT\nLateral ST-T changes may be due to myocardial ischemia, intraventricular\nconduction delay\nSince previous tracing, QRS interval width longer; ST-T wave abnormalities more\nmarked\n\n" }, { "category": "Nursing/other", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 1287457, "text": "1900-0700 rn notes micu\n\n53 y.o male with h/o CAD, CHF EF 20%, DMID,neuropathy presented to ED with weakness, dropping objects, feeling unwell a few days, where was found in ARF with hyperkalemia 7.8, wide QRS complex and ST elevation on ECG, received insulin IV, d50%,Bicarb, keyxaletee and lasix , unsucssefull attempt to put central line for dialysis,K at 1300 6.5Head CT done in ED d/t fall, c spine clear, no cervical collar needed.admitted to unit for further managment and follow lytes.\n\nneuro: intact,A/Ox3, follows commands, pt uses weelchair.\npt c/o of back and left leg pain, given Oxycodone 10mg PO.\n\nresp; NC 3L, LS clear dim at bases, sat 97%, no c/o SOB.\n\ncv: HR 100's, ST, no ectopy. BP 100-113/60, morning labs pending, at 0500 BP dropped to 86-89/50, given fluid bolus 500cc NS.\n\ngi/gu: pt voids 600ccx2, ABD soft.dist, BS +, no BM, Pt on fluid restriction 1500cc and daily weight, tollerates PO diet good.\n\nendo: p RISS and fixed dose at bedtime.\n\nskin: p thas dry ulcer on r foot, wet to dry dressing apllied.\n\naccess: 2piv.\nplan: cont follow lytes , next set at 0900 and 1400.\n follow BP and cardio status.\n check result of head CT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 1287458, "text": "in the morning K 4.9. BS FS at 0600 337, given 8u humolog.\n" }, { "category": "Nursing/other", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 1287459, "text": "in the morning K 4.9. BS FS at 0600 337, given 8u humolog.\n" }, { "category": "Nursing/other", "chartdate": "2120-11-24 00:00:00.000", "description": "Report", "row_id": 1287460, "text": "NPN 7a-7p:\n Review of systems:\n Neuro: pt A+O x 3. oob to commode with 1-2 assist x 3. reports no pain. refusing tylenol this afternoon. no s/s weakness, dropping things or numbness to lips as had prior to admit.. per renal, these were s/s associated with hyperkalemia.\n RESP: LS cta, rr 16-20. sats mid to high 90's on 3L NC, 88-90 on ra.\n CV: HR 90's. sbp 80's-110. received total 1.5 L ns bolus for hypotension.. however, team decided that as long as pt voiding and mentating ok, does not need fluid bolus as long as maps >55, which they are.\n FE: fsbs 244, receiving humalog insulin. repeat lyets this am, showed K+ 4.8, na 132 adn creat 2.5. 2pm lytes pending. pt tolerating heart healthy, diabetic diet. fluid balance 1L +.\n GI: pt with diarrhea x 2 today, cx spent. pt reports has been having diarrhea x 4 days or so.\n GU: voiding via commode in adequate amts.\n Access: 2 piv's.\n Integ: R foot with hard callous and podietry dressing.. do not remove podietry dressing per pt.. due to be changed wednesday.. has a pressure relieving sponge.. small breakdown to back of ankle.. cleaned and dressed with dsd.\n A/P: pt admit with renal failure/hyperkalemia, most likely r/t dehydration vs. recent increase in his ace inhibitor dose. lytes now normalizing, voiding. will continue to follow creat and potassium/na. will most likely need his glargine dose tonight.\n" }, { "category": "Nursing/other", "chartdate": "2120-11-25 00:00:00.000", "description": "Report", "row_id": 1287461, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT SLEPT WELL OVERNIGHT. PT GIVE OXYCODONE AT 2200 FOR DISCOMFORT. HELD 0200 TYLENOL, AT 0430 PT STILL DID NOT FEEL THAT HE NEEDED IT.\n\nRESP: PT CONT ON 3L NC. O2 SATS 90'S. LS CLEAR/\n\nCV: HR 80-90'S NSR. SBP 80-110'S. MAP GREATER THAN 55. AT 0400 MAP 50, PT WAS SLEEPING, AWAKE MAP 48. PT GIVEN 500CC NS BOLUS. AM LABS SENT, PENDING. PT .\n\nGI/GU: ABD SOFT, NO BM. PT VOIDING IN URINAL. NO U/O SINCE 2300. TEAM AWARE, PT DOESN'T FEEL HE HAS TO GO. PT TOLERATING . PM LANTUS GIVEN, 2200 BS 334.\n\nDISPO: AM LABS PEDNING. MONITOR SBP. ?T COULD BE CALLED OUT TO MEDICAL FLOOR TODAY. PT FULL CODE.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-11-25 00:00:00.000", "description": "Report", "row_id": 1287462, "text": "Nursing micu note of transfer:\n please see transfer note for all data. pt stable for transfer to floor.. bed available cc707.. orders written. pt transferred with this RN.\n" }, { "category": "Radiology", "chartdate": "2120-11-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 942019, "text": " 11:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL.ON COUMADIN.R/O BLEED\n Admitting Diagnosis: RENAL FAILURE, HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with severe cardiomyopathy, on coumadin s/p fall with INR 2.0\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old on Coumadin status post fall.\n\n No prior studies for comparison.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no evidence of hemorrhage, mass effect, shift of the\n normally midline structures, or infarction. The -white matter\n differentiation is preserved. There is no hydrocephalus. The paranasal\n sinuses and mastoid air cells are well aerated. The osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n 1. No hemorrhage or mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2120-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942015, "text": " 9:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cardiomyopathy and hyperkalemia\n REASON FOR THIS EXAMINATION:\n r/o effusion, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old with cardiomyopathy. Evaluate for effusion.\n\n COMPARISON: and .\n\n UPRIGHT CHEST RADIOGRAPH: The heart size is mildly enlarged. There is mild\n perihilar haziness. There is no pneumothorax. There are small bilateral\n pleural effusions. The left costophrenic angle is incompletely evaluated.\n\n IMPRESSION:\n\n 1. Mild CHF and small bilateral pleural effusions.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2176-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986001, "text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulm edema, pna, other intrathoracic pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hx CHF, now with increasing dyspnea\n REASON FOR THIS EXAMINATION:\n Evaluate for pulm edema, pna, other intrathoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP:\n\n COMPARISON: .\n\n HISTORY: CHF.\n\n FINDINGS: There is severe cardiomegaly, unchanged. There is increased\n interstitial markings and diffuse parenchymal air space opacities concerning\n for pulmonary edema. No large pleural effusions are identified.\n\n IMPRESSION: Cardiomegaly, pulmonary edema, not significantly changed.\n\n" }, { "category": "Radiology", "chartdate": "2176-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986139, "text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypertrophic cardiomyopathy, DM, a/w CHF exacerbation.\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Hypertrophic cardiomyopathy. CHF exacerbation.\n\n Comparison is made with prior study performed a day before.\n\n Marked cardiomegaly is unchanged. Allowing the technique that is limited due\n to patient body habitus, there has been no interval change in moderate\n pulmonary edema. There is no pneumothorax or sizeable pleural effusions.\n\n jr\n\n DR. \n" }, { "category": "Nursing/other", "chartdate": "2176-10-18 00:00:00.000", "description": "Report", "row_id": 1618829, "text": "Resp Care\nPt from Ed on NIPPV due to CHF. Pt on NIV for duration of the day. Pt taken off NIV and placed on NC 3 lpm. Current ABG: 7.43/59/65/40. Pt sats around 93. Pt has decreased. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2176-10-19 00:00:00.000", "description": "Report", "row_id": 1618834, "text": "Resp Care\nPt remains off mask ventilation, but may require it on @ noc. Pt currently on NC @ 3LPM. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2176-10-19 00:00:00.000", "description": "Report", "row_id": 1618832, "text": "55 YR. OLD WOMAN WITH H/O NON-OBSRUCTIVE CARDIOMYOPATHY, PAF, & CHF\nADMITTED THROUGH ED WITH ACUTE RESP DISTRESS D/T STOPPING PO LASIX @ HOME. GIVEN LASIX 40MG VP X1 IN ED->DIURESED 900CC. PLACED ON BIPAP.\nTRANSFERRED TO CCU FOR FURTHER MANAGEMENT. GIVEN ADDITONAL LASIX 40 MG VP X1 IN CCU->DIURESED ~800CC FOR TOTAL -1700. BIPAP OFF->3L NP.\u0013\n\nNEURO: DOZING, BUT EASILY AROUSABLE. A&O X3. PLEASANT & COOPERATIVE.\n\nRESP: O2->3L NP. O2 SAT 96-97%. RR 14-20. BS CLEAR WITH CRACKLES 1/2 UP BILATERALLY. ABG ON NP->7.41/60/76/39. PLACED ON BIPAP @ HS->50%/\nPS 10/PEEP 5. O2 SATS 99-100%.\n\nCARDIAC: HR 61->50 SR/SB, NO ECTOPY. METOPROLOL XL DECREASED FROM 100MG->50MG. BP 89-102/29-58. ~0100 SBP 80 WITH LOW-NO U/O. HO AWARE.\nWATCHED FOR A BIT, THEN GAVE 250CC NS BOLUS. SBP BRIEFLY 90, THEN BACK TO 80'S. GIVEN ADDITIONAL 250CC NS. HCT 27.7, K 4.2, MG 1.7->MAG SULFATE 2GMS PB X1. REPEAT MG 2.7. CK 157 WITH MB 8.\n\nGI: ABD. OBESE. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING AMBER URINE. U/O 10-30CC/HR. HO AWARE.\nWITH SBP 80'S, NO U/O X1 HR. 250CC NS BOLUS X2. U/O 15-25CC/HR. BUN/CREAT 16/1.3.\n\nID: T 99.4->98.3(PO). WBC 7.2.\n\nENDO: BS 99 @ HS. 1/2 DOSE LANTIS GIVEN. ~0130 BS 71->OJ X2. REPEAT BS 126.\n\nAM LABS SENT. HCT 27, PLAT CT 280, CK 149 WITH MB 7. K 4.7, MG 2.5.\n\nPLAN: CLOSELY MONITOR BP/U/O. DIURESE WHEN ABLE.\n MONITOR HCT,LYTES & REPLETE AS NEEDED.\n SOCIAL SERVICE CONSULT TO DEAL WITH ISSUES AT HOME.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-10-19 00:00:00.000", "description": "Report", "row_id": 1618833, "text": "CCU Nursing Progress Note 0700-1900\nS: denies SOB\n\nO: see CCU flow sheet for complete objective data\n\nCV: 86/37, but 120/60 by cuff. cuff changed to long cuff (from large adult cuff)-->BP 129/52. BP 112-140/41-56. Tolerating lisinopril, Toprol and aldactone.\n\nResp: removed from bi-pap when awokened this am. Sats >95% on 3L NP. When placed flat, sats dropped to 82%. HOB ^, with Sat up to 90%. O2 ^ to 6L NP. Able to titrate back to the 3L NP.\n\nGI: excellent appetite. Had received usual dose of Humalog last evening d/t poor appetite. BS 78 before breakfast, 158 before lunch-->2 units Humalog. Abd obese, soft, + BS. Loose brown OB negative stool\n\nGU: Foley d/c'd as per team @ 1130. DTV between 1730 and . Urine this am amber with sediment.\n\nSkin: Left hip allevyn dressing in place (site not visualized). Pt states that it is an area that she had been rubbing with her fingernails.\n\nSoc: daughter called and updated on .\n\nA: tolerating additon of anti-HTN meds without drop in pressure. Desat with HOB flat, Ok with HOB @ 45-90 degrees.\n\nP: Pt ok to transfer to , awaiting bed. Continue to monitor HR/Rhythm/BP. Monitor blood sugar on lantus q pm with SS Humalog coverage. Assess Left hip when allevyn dressing removed. Assess for desat with HOB down.\n" }, { "category": "Nursing/other", "chartdate": "2176-10-18 00:00:00.000", "description": "Report", "row_id": 1618830, "text": "Nursing Progress Note 1200-\nS: \"My breathing feels better now.\"\n\nO: Please see carevue for objective data.\n\nPt is 55yo female with 4 hospital admissions this year for CHF exacerbations on home O2, CPAP, lasix, BB. Called 911 this AM for acute SOB in setting of stopping lasix for a few days. Pt states this was b/c her bathroom was being repaired by landlord and had to use neighbors' facilities which was too far to walk given her dyspnea. Also, CPAP machine reportedely not functioning properly. Given IV lasix in ED 40mg with 900ml urine out. Admitted to CCU on BiPAP for futher diuresis/ CHF mgt.\n\nCV: Telemetry 60s-70s SR with rare PVC. BP on arrival to CCU 160s-180s/80s. Given 40mg IV lasix x one with over 1 liter Urine out in 2 hours. Routine AM meds given and BP down to 100s-140s/60s. Palp DP/PT bilaterally. +LE edema. EKG on admission with TWI and ST depressions V5-V6. HCT in ED=32.1. Repeat in CCU: 27.9 Recheck @ 24:00.\n\nNeuro: A&Ox3. Denied pain.\n\nResp: Arrived on BiPAP 5/5, FiO2 40% with SPO2 97-100%. LS: rales lower , +accessory muscle use. No cough. RR: 25-30 on arrival. After IV lasix, pt with increased resp comfort and BiPap changed to 3LNC. ABGs on 3L NC: 7.43/59/65/40. SPO2 91-99% 3L.\n\nGI/GU: Abdomen obese, soft, NT, ND. +BS x 4 quad. Med BM , guiac negative. FS QID. Foley cath placed today with clear, light yellow urine.\n\nSkin: Warm, dry. L lateral aspect of leg with closed ulcerations of unknown origin per patient.\n\nAccess: PIV R Ant FA . PIV L hand D/c'd on arrival as falling out. Attempted to place another PIV without success. Team aware of difficult access.\n\nPLAN: Continue CHF mgt. Goal diuresis -2L/day. Continue to monitor resp status on 3L NC. Follow hemodynamics. Labs due @ 24:00 including repeat HCT and T&S. Cycling enzymes. Coumadin for hx PAF. FS QID. Nutrition consult, social work consult (for resources given med non-compliance r/t lack of accessible bathroom).\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-10-19 00:00:00.000", "description": "Report", "row_id": 1618831, "text": "Resp Care Note, Pt remains on current NIV settiings. See vent flow sheet for details. BS wheezes given albuterol MDI'S and atrovent nebs along with flowvent MDI. Stable tol NIV without problem. cont to monitor resp status.\n" }, { "category": "ECG", "chartdate": "2176-10-18 00:00:00.000", "description": "Report", "row_id": 273663, "text": "Sinus rhythm with atrial premature beats. Probable left ventrticular\nhypertrophy with secondary repolarization abnormalities. Non-specific\nST-T wave abnormalities. Compared to prior tracing earlier same date\nheart rate has decreased. ST-T wave abnormalities are less marked.\nSuggest clinical correlation.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-10-18 00:00:00.000", "description": "Report", "row_id": 273664, "text": "Probable sinus tachycardia. Probable left ventricular hypertrophy with\nsecondary repolarization abnormalities. Non-specific ST-T wave abnormalities.\nCompared to prior tracing of tachycardia is new and ST-T wave\nabnormalities are more marked. Suggest clinical correlation and repeat\ntracing.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2176-10-20 00:00:00.000", "description": "Report", "row_id": 273661, "text": "Sinus rhythm. The Q-T interval is prolonged. Left ventricular hypertrophy.\nDiffuse non-specific ST-T wave changes. Compared to the prior tracing\nST-T wave changes are more extensive.\n\n" }, { "category": "ECG", "chartdate": "2176-10-19 00:00:00.000", "description": "Report", "row_id": 273662, "text": "Sinus bradycardia. Probable left ventricular hypertrophy with\nsecondary repolarization abnormalities. Q-T interval prolonged for rate.\nNon-specific ST-T wave abnormalities. Compared to prior tracing\nearlier on the heart rate has decreased further. Atrial premature\nbeats are no longer seen.\nTRACING #3\n\n" } ]

[ { "category": "Radiology", "chartdate": "2130-07-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1197855, "text": " 9:23 PM\n CHEST (PA & LAT) Clip # \n Reason: ?pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with abdominal pain, tachypnea\n REASON FOR THIS EXAMINATION:\n ?pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CHEST, FRONTAL AND LATERAL VIEWS.\n\n CLINICAL INFORMATION: 72-year-old male with history of abdominal pain,\n tachypnea.\n\n COMPARISON: CT torso from .\n\n FINDINGS: Frontal and lateral views of the chest are obtained. Left base\n linear atelectasis/scarring are seen. There is mild elevation of the right\n hemidiaphragm. No focal consolidation, large pleural effusion, or evidence of\n pneumothorax is seen. The cardiac silhouette demonstrates left ventricular\n configuration, but is not frankly enlarged. The mediastinum and hilar\n contours are unremarkable. A right Port-A-Cath distal aspect not well seen,\n but likely terminating in the right atrium.\n\n IMPRESSION: Left base linear atelectasis/scarring. No acute cardiopulmonary\n process.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-07-23 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1197860, "text": " 11:21 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: mesenteric ischemia vs. abscess vs enteritis\n Field of view: 33 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with abd pain s/p SB resection, rising lactate, resolved SBO\n today.\n REASON FOR THIS EXAMINATION:\n mesenteric ischemia vs. abscess vs enteritis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy MON 1:06 AM\n 1. diffuse small bowel dilation extending to LLQ ostomy with massively\n dilated stomach. imaging findings suggest SBO though given clinical\n resolution and good ostomy output this could reflect resolving obstruction.\n 2. no convincing evidence of bowel ischemia. small bowel wall enhances\n normally. no pneumatosis. a single prox jej loop in the RUQ demonstrates\n mild wall thickening though likely exagerrated by relative collapse of this\n loop. no free air, no sig free fluid. mesenteric vessels appear patent.\n 3. large pelvis mass c/w known mucinous adenicarcinoma. this mass contains\n multiple foci of air, which raise concern for fistulous connection with GI\n tract, including either distal colon (encased by the mass) or duodenum (where\n there is apparent loss of duodenal wall continuity where it contacts the\n mass). this would be further evaluated with study with oral and rectal\n contrast.\n 4. mild left hydronephrosis/hydroureter, likely sec to pelvis mass\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with intra-abdominal mucinous adenocarcinoma,\n presumed metastatic from the appendix, presenting with resolving small-bowel\n obstruction (currently good ostomy output), and elevated though falling\n lactate.\n\n COMPARISON: PET CT .\n\n TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed following the\n uneventful intravenous administration of contrast material. Multiplanar\n reformats were prepared and reviewed.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n There is airspace consolidation medially in the right lower lobe, concerning\n for pneumonia or aspiration. There is no pleural effusion. The left lung\n base is clear. There is no pericardial effusion.\n\n There is a small hypodense lesion within the right lobe of the liver, too\n small to characterize, though unchanged from . An additional\n hypodense lesion more inferiorly within the right lobe, also unchanged. There\n is no intrahepatic biliary ductal dilation. The gallbladder is unremarkable.\n The spleen, pancreas, adrenal glands, and right kidney are similarly\n unremarkable.\n (Over)\n\n 11:21 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: mesenteric ischemia vs. abscess vs enteritis\n Field of view: 33 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is however new mild left hydronephrosis and hydroureter, extending to\n the pelvic mass, and likely reflecting compression by the structure. There is\n relative delayed contrast excretion from the left kidney.\n\n The stomach is massively distended. There are diffusely dilated small bowel\n loops seen throughout the abdomen, extending to the patient's left lower\n quadrant ostomy. Small bowel loops measure up to 4 cm. While the imaging\n findings are suggestive of a a current distal obstruction, given clinical\n resolution of symptoms and good ostomy output, this may reflect a resolving\n obstruction. Small bowel wall uniformly enhances, with no hypoenhancing\n segments to definitively suggest ischemia. There is no pneumatosis or portal\n venous air identified. A single loop of small bowel in the right upper\n quadrant does demonstrate wall thickening, which may be exageratted by\n collapse, but could nonetheless reflect an inflammatory process.\n\n There is fecal material identified throughout the colon. The source of this\n is unclear, give apparent end ileostomy in the left lower quadrant, though it\n may reflect accumulation of secretions due to obstructive effect of pelvic\n mass.\n\n The aorta is normal in caliber. The major mesenteric vessels are patent.\n There is no significant atherosclerotic disease. There is no free air in the\n abdomen. There is trace free fluid in the left and right upper quadrants.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST:\n\n There is a large, cavitary pelvic mass identified, compatible with known\n mucinous adenocarcinoma. In comparison to recent PET-CT , this\n mass has enlarged, currently measuring up to 10.5 x 13.5 cm in the axial\n plane, where previously measuring 4.8 x 10 cm. Cavitation may reflect\n necrosis, though note is also made that the mass encases and is inseparable\n from the sigmoid colon and cecum, as well as superiorly abuts the third\n portion of the duodenum, where there is apparent discontinuity of the duodenal\n wall (601B:30 and 602B:34). Thus, the air within the pelvic lesion may also\n reflect enteric fistulization. Superinfection cannot be excluded by imaging.\n A study performed with rectal and oral contrast may be helpful for further\n delineation of this process and anatomy, if clinically relevant.\n\n A Foley catheter decompresses the bladder, with associated air within the\n bladder. There is no inguinal adenopathy. Femoral and iliac vessels are\n patent. There is no DVT identified.\n\n BONE WINDOWS: There are thoracolumbar degenerative changes, worst at L5-S1,\n where bilateral spondylolysis and associated grade 1 anterolisthesis is noted.\n There are no lytic or sclerotic osseous lesions.\n (Over)\n\n 11:21 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: mesenteric ischemia vs. abscess vs enteritis\n Field of view: 33 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. Large cavitary pelvic mass, consistent with known mucinous adenocarcinoma.\n This has enlarged compared to . The cavitation and internal air raise\n concern for either necrosis or fistulous connection with the GI tract,\n including either the distal colon (encased by the mass), cecum, or duodenum\n (where there is apparent loss of duodenal wall continuity where it contacts\n the mass and third portion). This anatomy could be further evaluated with a\n study performed with both oral and rectal contrast, if clinically relevant.\n\n 2. Diffuse small bowel dilatation extending to left lower quadrant ostomy,\n with massively dilated stomach. The imaging findings are suggestive of distal\n small-bowel obstruction, but given the clinical resolution and reportedly good\n ostomy output, this could reflect a resolving obstruction.\n\n 3. No definite evidence of bowel ischemia, as questioned. The small bowel\n enhances normally, and there is no pneumatosis. A single proximal jejunal\n loop in the right upper quadrant does demonstrate wall thickening, which while\n likely exaggerated by relative collapse could reflect an inflammatory process\n including possible element of ischemia.\n\n 4. Retained stool within the colon, which, given reportedly discontinuous GI\n tract, may reflect accumulation of mucus/secretions secondary to relative\n obstruction by pelvic mass.\n\n 5. Mild left hydronephrosis and hydroureter, extending into the pelvis,\n likely secondary to compressive effect of the pelvic mass.\n\n\n" }, { "category": "ECG", "chartdate": "2130-07-23 00:00:00.000", "description": "Report", "row_id": 224852, "text": "Sinus rhythm. Small inferior Q waves of uncertain significance. Poor R wave\nprogression. Compared to the previous tracing of there is no\nsignificant interval change.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2180-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694890, "text": "Chief Complaint: chest pain\n 24 Hour Events:\n no overnight events\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:12 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 Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n productive green/yellow sputum\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: Dialysis\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:33 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: 36.2\nC (97.2\n HR: 78 (76 - 87) bpm\n BP: 104/64(73) {80/29(44) - 117/72(82)} mmHg\n RR: 20 (11 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Diaphoretic,\n mildly diaphoretic\n Eyes / Conjunctiva: PERRL, EOMi\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : bibasilar, Bronchial: right posterior lung,\n Rhonchorous: right posterior lung)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 9.2 g/dL\n 87 mg/dL\n 9.3 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 67 mg/dL\n 95 mEq/L\n 136 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n WBC\n 8.0\n 7.0\n 9.4\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n Plt\n 167\n 139\n 151\n Cr\n 5.5\n 7.7\n 9.3\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 31\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n Other labs: PT / PTT / INR:12.9/26.9/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.1 mg/dL, Mg++:3.5\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -cont metoprolol 25mg PO BID\n -cont Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -lisinopril 2.5mg daily -> will hold anti-hypertensives pre-dialysis\n given low SBP 80s\n .\n # cough/sputum production: concern for hospital-acquired PNA, although\n pt afebrile\n - will consider PA/lateral, defer empiric therapy for now\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol yesterday\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> appreciate input, will check PTH\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\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 would add the following remarks:\n History\n Nothing to add, will insert line (groin) today\n Physical Examination\n Nothing to add,\n Medical Decision Making\n Nothing to add,\n Total time spent on patient care: 50 minutes.\n" }, { "category": "Physician ", "chartdate": "2180-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694894, "text": "Chief Complaint: chest pain\n 24 Hour Events:\n no overnight events\n no chest pain for > 48 hours; does have cough productive of green\n sputum, denies dyspnea, fevers, or chills\n no other complaints\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:12 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n productive green/yellow sputum\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: Dialysis\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:33 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: 36.2\nC (97.2\n HR: 78 (76 - 87) bpm\n BP: 104/64(73) {80/29(44) - 117/72(82)} mmHg\n RR: 20 (11 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Diaphoretic,\n mildly diaphoretic\n Eyes / Conjunctiva: PERRL, EOMi\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : bibasilar, Bronchial: right posterior lung)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 9.2 g/dL\n 87 mg/dL\n 9.3 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 67 mg/dL\n 95 mEq/L\n 136 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n WBC\n 8.0\n 7.0\n 9.4\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n Plt\n 167\n 139\n 151\n Cr\n 5.5\n 7.7\n 9.3\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 31\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n Other labs: PT / PTT / INR:12.9/26.9/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.1 mg/dL, Mg++:3.5\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -cont metoprolol 25mg PO BID\n -discontinue Imdur\n -lisinopril 2.5mg daily -> will hold anti-hypertensives pre-dialysis\n given SBP 90s to 100s\n .\n # cough/sputum production: concern for hospital-acquired PNA, although\n pt afebrile; no white count, but trending up\n - defer empiric therapy for now\n - if patient still has O2 requirement post-dialysis today, consider PA\n and lateral chest film and empiric antibiotic treatment of HAP\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -added ACE inhibitor\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, metoprolol\n .\n # Hypotension: Initially managed with dopamine given peripherally with\n goal to maintain pressures above 90s-100s systolic, now off dopa, doing\n well\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code.\n Versed/Fentanyl was needed for sedation on vent. Patient now extubated\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n -Hct continues to normalize\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> appreciate input, will check PTH\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Full\n .\n DISPO: possible d/c today if no O2 requirement post-dialysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2180-08-29 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 695057, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: Pt. is 67 y.o. male,\n blind and deag, admitted with OSH with burning chest pain. Ruled out\n for MI. Returned to next day with chest pain, taken to cath lab,\n successful stenting of distal LAD, unable to tolerate further \n agitation. Tranferred to floor, continued to have chest pain overnight.\n Returned to cath lab next day, procedure c/b LMCA artery dissection,\n and pt. cardiac arrested. CPR initiated. Intubated and taken to unit,\n needing dopamine to maintain BP. Extubated next day.\n Past Medical / Surgical History: Dyslipidemia, Htn, Dilated\n cardiomyopathy, NSTEMI,a-fib, ESRD on HD, Gout, Congenital deafness,\n retinitis pigmentosa, speech deficit\n Medications: Allopurinol, Amiodarone, Aspirin, Atorvastatin,\n Clopidogrel, Nephrocaps, Lisinopril, Metoprolol, Nitroglycerin,\n Radiology: CXR: In comparison with study of , the nasogastric\n tube has been pushed forward slightly so that the side hole appears to\n extend beyond the esophagogastric junction. Endotracheal tube has been\n removed. Progressive improvement in pulmonary vascular status.\n Labs:\n 30.6\n 9.6\n 171\n 7.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\n Social / Occupational History: -ETOH/Tobacco, Unemployed on disability.\n Lives with girlfriend.\n Environment: 1 STE, 1 level apt.\n Prior Functional Status / Activity Level: PTA. Amb. With SC, Owns\n rollator, uses sometimes. Uses Ride. Has Homemaker 5 x/wk for meals.\n Objective Test\n Arousal / Attention / Cognition / Communication:\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 82\n 93/47\n 10\n 98 on RA\n Activity\n 88\n 120/60\n 12\n 92-97 on RA\n Stand\n /\n Recovery\n 96\n 95/60\n 10\n 96 onRA\n Total distance walked: 200\n Minutes: 6\n Pulmonary Status: BS dimished at bases\n Integumentary / Vascular: R UE PIV, telemetry\n Sensory Integrity: no c/o parethesias\n Pain / Limiting Symptoms: no c/o pain\n Posture: WNL\n Range of Motion\n Muscle Performance\n Bilat. UEs/LEs: WFL throughout\n Bilat. UEs/LEs: > throughout\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. amb 200 ft with SC, with S vision\n impairment.\n Rolling:\n Received in sitting\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n x\n\n\n\n\n\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n x\n\n\n\n\n Ambulation:\n x\n\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: No LOB during ambulation with SC\n Education / Communication: Pt. edu re: role of PT, , d/c plan home\n with PT, RN comm. Re: Pt. status, d/c plan home,\n M.D. comm. Re: Pt. status, d/c plan home\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Knowledge, Impaired\n Clinical impression / Prognosis: Pt. is 67 y.o. male with CAD,\n cardiomyopathy s/p cardiac arrest during cardiac catherization that p/w\n above impairments associated with cardiac pump dysfunction. Pt. appears\n to be functioning close to baseline and has met all STGs. Anticipate\n d/c home once medically ready. No further acute PT needs. Recommend\n home safey evaluation upon discharge home.\n Goals\n Time frame: met on eval\n 1.\n Sit to stand with S\n 2.\n Amb 200 ft with SC with S\n 3.\n Maintain SpO2 > 92% on RA\n 4.\n Communicate understanding of Role of PT\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan: d/c acute PT\n Frequency / Duration:\n X Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face time: 9-9:33 am\n Nsg recs: Amb with SC with S, 3x/day\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695063, "text": "Knowledge, Impaired\n Assessment\n Pt hoh and legally blind\n Action:\n Asl interpreter participated in discharge teaching, caritas vna\n notified of need for asl when seeing pt\n Response:\n Plan:\n Discharge to home c vna,pt Thursday ,dialysis wenesday and followup\n appointment c dr \n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Sr no ect bp tol cardiac meds,no bleeding from cath sites , pulses palp\n Action:\n Ambulated c PT\n Response:\n Sat 95 rm air, no cp,bp stable\n Plan:\n DC TO HOME\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694970, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n - overnight patient tolerated cardiac meds, oob to chair &\n commode with 1 assist\n" }, { "category": "Physician ", "chartdate": "2180-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694761, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Extubated this AM- did well. Now off pressors. Had one episode of\n chest pain which required SL nitro. No EKG changes noted- pain\n resolved. Restarted imdur this PM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 08:08 AM\n Famotidine (Pepcid) - 08:45 AM\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 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 85 (85 - 111) bpm\n BP: 112/69(82) {96/36(63) - 117/73(83)} mmHg\n RR: 12 (11 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 1,134 mL\n PO:\n 240 mL\n TF:\n IVF:\n 377 mL\n Blood products:\n 397 mL\n Total out:\n 200 mL\n 0 mL\n Urine:\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 934 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 674 (674 - 674) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 2%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: 7.44/35/98.//0\n Ve: 7.5 L/min\n PaO2 / FiO2: 4,900\n Physical Examination\n GENERAL: Caucasian male. NAD\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 167 K/uL\n 9.7 g/dL\n 94 mg/dL\n 5.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.8 %\n 8.0 K/uL\n [image002.jpg]\n 07:30 PM\n 07:47 PM\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n WBC\n 7.7\n 8.0\n Hct\n 24.8\n 28.4\n 30\n 29.8\n 28.8\n Plt\n 153\n 167\n Cr\n 4.6\n 5.5\n TropT\n 0.50\n 0.65\n 0.56\n TCO2\n 31\n 31\n 32\n 31\n 24\n 25\n Glucose\n 140\n 94\n Other labs: CK / CKMB / Troponin-T:120/5/0.56, Lactic Acid:0.7 mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start low dose metoprolol when patient off of pressors\n -Hold home Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -EKG, ECHO in AM\n -Will add an ACE inhibitor when BP allows\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol when pressures stabilize off of\n pressors\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor when BP stable\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\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 would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 50 minutes.\n" }, { "category": "Physician ", "chartdate": "2180-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694762, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Extubated this AM- did well. Now off pressors. Had one episode of\n chest pain which required SL nitro. No EKG changes noted- pain\n resolved. Restarted imdur this PM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 08:08 AM\n Famotidine (Pepcid) - 08:45 AM\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 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 85 (85 - 111) bpm\n BP: 112/69(82) {96/36(63) - 117/73(83)} mmHg\n RR: 12 (11 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 1,134 mL\n PO:\n 240 mL\n TF:\n IVF:\n 377 mL\n Blood products:\n 397 mL\n Total out:\n 200 mL\n 0 mL\n Urine:\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 934 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 674 (674 - 674) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 2%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: 7.44/35/98.//0\n Ve: 7.5 L/min\n PaO2 / FiO2: 4,900\n Physical Examination\n GENERAL: Caucasian male. NAD\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 167 K/uL\n 9.7 g/dL\n 94 mg/dL\n 5.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.8 %\n 8.0 K/uL\n [image002.jpg]\n 07:30 PM\n 07:47 PM\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n WBC\n 7.7\n 8.0\n Hct\n 24.8\n 28.4\n 30\n 29.8\n 28.8\n Plt\n 153\n 167\n Cr\n 4.6\n 5.5\n TropT\n 0.50\n 0.65\n 0.56\n TCO2\n 31\n 31\n 32\n 31\n 24\n 25\n Glucose\n 140\n 94\n Other labs: CK / CKMB / Troponin-T:120/5/0.56, Lactic Acid:0.7 mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start metoprolol 25mg PO BID this am\n -Imdur restarted this AM\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -ECHO in AM\n -EKG\n -lisinopril 2.5mg daily\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol yesterday\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694763, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Extubated this AM- did well. Now off pressors. Had one episode of\n chest pain which required SL nitro. No EKG changes noted- pain\n resolved. Restarted imdur this AM. Metoprolol and lisinopril started\n yesterday.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 08:08 AM\n Famotidine (Pepcid) - 08:45 AM\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 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 85 (85 - 111) bpm\n BP: 112/69(82) {96/36(63) - 117/73(83)} mmHg\n RR: 12 (11 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 1,134 mL\n PO:\n 240 mL\n TF:\n IVF:\n 377 mL\n Blood products:\n 397 mL\n Total out:\n 200 mL\n 0 mL\n Urine:\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 934 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 674 (674 - 674) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 2%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: 7.44/35/98.//0\n Ve: 7.5 L/min\n PaO2 / FiO2: 4,900\n Physical Examination\n GENERAL: Caucasian male. NAD\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 167 K/uL\n 9.7 g/dL\n 94 mg/dL\n 5.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.8 %\n 8.0 K/uL\n [image002.jpg]\n 07:30 PM\n 07:47 PM\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n WBC\n 7.7\n 8.0\n Hct\n 24.8\n 28.4\n 30\n 29.8\n 28.8\n Plt\n 153\n 167\n Cr\n 4.6\n 5.5\n TropT\n 0.50\n 0.65\n 0.56\n TCO2\n 31\n 31\n 32\n 31\n 24\n 25\n Glucose\n 140\n 94\n Other labs: CK / CKMB / Troponin-T:120/5/0.56, Lactic Acid:0.7 mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start metoprolol 25mg PO BID this am\n -Imdur restarted this AM\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -ECHO in AM\n -EKG\n -lisinopril 2.5mg daily\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol yesterday\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694772, "text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694773, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n \n Rec\nd 2uprbc\ns post procedure for hct . Sedation dc\nd f/b\n extubation and rapid Dopa wean maintaining HR 80\ns and BP 110-120\n Able to wean O2 to 2ln/p. Lopressor and lisinopril added to regime in\n pm. c/o cp and rec\nd i sl NTG w/ relief. No ECG changes.\n \n BP slightly lower post administration of all card meds\n 110>>86/. Pt slightly lightheaded, but mentating.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt communicates with ASL; able to verbally communicate needs fairly\n well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily to keep pt updated on condition, plan\n of care; on-call interpreter as needed.\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695028, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n - overnight patient tolerated cardiac meds, oob to chair &\n commode with 1 assist. 1 episode chest burning (? Anxiety) resolved\n quickly with GI cocktail.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Patient with 2 complicated cardiac cath\ns this admission (8/27&)\n with interventions as above. Chest Pain free & hemodynamically stable\n overnight. HR 80-90 SR, no ectopy, & NBP range 99-105/60\n Action:\n o Monitored for any c/o CP discomfort.\n o Hemodynamic monitoring, Monitored groin sites.\n o 25 mg lopressor given\n Response:\n o 1 episode c/o chest\nburning\n upon awakening at 0330- EKG\n obtained, MD notified and patient given GI cocktail. Discomfort quickly\n resolved, MD met with patient & he quickly returned to sleep. No SL NTG\n given.\n o Hemodynamically stable, tolerated lopressor dose,\n o Groin sites remain intact. Occasionally expectorating\n blood-tinged sputum (s/p extubation ) remains afebrile.\n Plan:\n Continue to monitor hemodynamic status. Monitor for c/o CP/discomfort-\n ? anxiety component given difficult course. Continue cardiac medication\n regimen as tolerated within parameters. Monitor for s/s\n fever/infection.\n Impaired Physical Mobility\n Assessment:\n Patient awaiting PT consult prior to discharge. Mobility compromised by\n vision deficit as well as potentially by his hearing deficit. Visited\n by case manager & social worker prior shift to facilitate safe\n discharge plan including arrangement for medications.\n Action:\n o 1 assist from chair-bed-commode, patient calls appropriately\n for assistance, bed alarm maintained and call bell within reach.\n o Spoke into patient\ns right ear to maximize communication as\n patient with vision & hearing deficits\n Response:\n o Patient continues to call appropriately for assistance,\n occasionally sitting at edge of bed without calling for help first, but\n no attempts OOB.\n o Recommend using ASL translator for assisting with PT consult\n & discharge planning. Patient able to clearly state/verbalize his needs\n but noted overnight that he had difficulty understanding questions &\n explanations being offered to him- ASL interpreter hours posted in\n room.\n Plan:\n PT consult. Case management & social work involvement with discharge\n home- will have VNA. ASL interpreter as needed. Continue to maintain\n safety OOB and with activity.\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695029, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n - overnight patient tolerated cardiac meds, oob to chair &\n commode with 1 assist. 1 episode chest burning (? Anxiety) resolved\n quickly with GI cocktail.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Patient with 2 complicated cardiac cath\ns this admission (8/27&)\n with interventions as above. Chest Pain free & hemodynamically stable\n overnight. HR 80-90 SR, no ectopy, & NBP range 99-105/60\n Action:\n o Monitored for any c/o CP discomfort.\n o Hemodynamic monitoring, Monitored groin sites.\n o 25 mg lopressor given\n Response:\n o 1 episode c/o chest\nburning\n upon awakening at 0330- EKG\n obtained, MD notified and patient given GI cocktail. Discomfort quickly\n resolved, MD met with patient & he quickly returned to sleep. No SL NTG\n given.\n o Hemodynamically stable, tolerated lopressor dose,\n o Groin sites remain intact. Occasionally expectorating\n blood-tinged sputum (s/p extubation ) remains afebrile.\n Plan:\n Continue to monitor hemodynamic status. Monitor for c/o CP/discomfort-\n ? anxiety component given difficult course. Continue cardiac medication\n regimen as tolerated within parameters. Monitor for s/s\n fever/infection.\n Impaired Physical Mobility\n Assessment:\n Patient awaiting PT consult prior to discharge. Mobility compromised by\n vision deficit as well as potentially by his hearing deficit. Visited\n by case manager & social worker prior shift to facilitate safe\n discharge plan including arrangement for medications.\n Action:\n o 1 assist from chair-bed-commode, patient calls appropriately\n for assistance, bed alarm maintained and call bell within reach.\n o Spoke into patient\ns right ear to maximize communication as\n patient with vision & hearing deficits\n Response:\n o Patient continues to call appropriately for assistance,\n occasionally sitting at edge of bed without calling for help first, but\n no attempts OOB.\n o Recommend using ASL translator for assisting with PT consult\n & discharge planning. Patient able to clearly state/verbalize his needs\n but noted overnight that he had difficulty understanding questions &\n explanations being offered to him- ASL interpreter hours posted in\n room.\n Plan:\n PT consult. Case management & social work involvement with discharge\n home- will have VNA. ASL interpreter as needed. Continue to maintain\n safety OOB and with activity.\n" }, { "category": "Physician ", "chartdate": "2180-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 695036, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt had episode of chest pain at end of dialysis session. Pt sat up, and\n was given sublingual nitrate which relieved pain. EKG was unchanged\n from prior. Pt also had all cardiac meds held because of hypotension\n earlier in the day. Given daily metoprolol, lisinopril, 90 of Imdur.\n Will likely need 120 of Imdur and toprol XL upon d/c, planned for\n tomorrow. Another episode of CP at 3:30 AM, sitting up c/o \"burning,\n relieved w/ GI cocktail, VSS, EKG unchanged from previous. No\n sublingual nitrate given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\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: denies chest pain this morning, coughing occasional\n with associated burning chest pain. No SOB, no fevers/chills, anxious\n overnight, and had trouble sleeping\n Flowsheet Data as of 05:50 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: 36.8\nC (98.2\n HR: 85 (74 - 93) bpm\n BP: 104/61(71) {76/41(49) - 115/73(107)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75 kg (admission): 68 kg\n Total In:\n 660 mL\n 120 mL\n PO:\n 660 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///32/\n Physical Examination\n Sitting at edge of bed, NAD, A and O x 3\n HEENT- normocephalic, atraumatic\n CV\n RRR, S1, S2, no m,r,g. JVD at about 7 cm. PMI non-displaced\n Pulm- rales left base, otherwise CTA, improved from yesterday\n Abd- soft, NT, ND, active BS, no HSM\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No rash\n Neurologic: CNs II\n XII intact, ambulatory\n Labs / Radiology\n 171 K/uL\n 9.6 g/dL\n 101 mg/dL\n 6.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 35 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.6 %\n 7.8 K/uL\n [image002.jpg]\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n 03:49 AM\n WBC\n 8.0\n 7.0\n 9.4\n 7.8\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n 30.6\n Plt\n 167\n 139\n 151\n 171\n Cr\n 5.5\n 7.7\n 9.3\n 6.1\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n 101\n Other labs: PT / PTT / INR:12.6/28.6/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 67 y/o blind, deaf male w/ESRD, s/p cath on \n with stenting of distal LAD stenosis with continued to have chest pain\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with prximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient has continued to ask for nitroglycerin for chest\n pain overnight, including when he triggered this morning for same\n request. EKG's consistently unchanged. Unrelieved with maalox, GI\n cocktail. Trop 0.63 this morning. Was 0.97 at OSH. Elevated troponin\n may include component of CHF and renal failure, given flat CK.\n -Aspirin, plavix, imdur, metoprolol, lipitor; pt will likely need imdur\n upon d/c for angina/burning chest pain\n -added ACE inhibitor, BP stable\n -chest pain episodes yesterday resolved with SL NTG and then GI\n cocktail\n .\n # PUMP: Has known cardiomyopathy with EF 35% on Echo. No overt\n clinical signs of heart failure at this time. No peripheral edema,\n crackles, or JVD.\n -on ACEi\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, metoprolol\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%\n - pt no longer has O2 requirement after dialysis yesterday, pneumonia\n unlikely.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct stable\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> 1.5 liters removed yesterday during HD\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: full\n .\n DISPO: likely d/c today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2180-08-29 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 695048, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: Pt. is 67 y.o. male,\n blind and deag, admitted with OSH with burning chest pain. Ruled out\n for MI. Returned to next day with chest pain, taken to cath lab,\n successful stenting of distal LAD, unable to tolerate further \n agitation. Tranferred to floor, continued to have chest pain overnight.\n Returned to cath lab next day, procedure c/b LMCA artery dissection,\n and pt. cardiac arrested. CPR initiated. Intubated and taken to unit,\n needing dopamine to maintain BP. Extubated next day.\n Past Medical / Surgical History: Dyslipidemia, Htn, Dilated\n cardiomyopathy, NSTEMI,a-fib, ESRD on HD, Gout, Congenital deafness,\n retinitis pigmentosa, speech deficit\n Medications: Allopurinol, Amiodarone, Aspirin, Atorvastatin,\n Clopidogrel, Nephrocaps, Lisinopril, Metoprolol, Nitroglycerin,\n Radiology: CXR: In comparison with study of , the nasogastric\n tube has been pushed forward slightly so that the side hole appears to\n extend beyond the esophagogastric junction. Endotracheal tube has been\n removed. Progressive improvement in pulmonary vascular status.\n Labs:\n 30.6\n 9.6\n 171\n 7.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB\n Social / Occupational History: -ETOH/Tobacco, Unemployed on disability.\n Lives with girlfriend.\n Environment:\n Prior Functional Status / Activity Level: PTA.\n Objective Test\n Arousal / Attention / Cognition / Communication:\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 /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status:\n Integumentary / Vascular:\n Sensory Integrity:\n Pain / Limiting Symptoms:\n Posture:\n Range of Motion\n Muscle Performance\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:\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\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance:\n Education / Communication:\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Knowledge, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2180-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 695052, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt had episode of chest pain at end of dialysis session. Pt sat up, and\n was given sublingual nitrate which relieved pain. EKG was unchanged\n from prior. Pt also had all cardiac meds held because of hypotension\n earlier in the day. Given daily metoprolol, lisinopril, 90 of Imdur.\n Will likely need 120 of Imdur and toprol XL upon d/c, planned for\n tomorrow. Another episode of CP at 3:30 AM, sitting up c/o \"burning,\n relieved w/ GI cocktail, VSS, EKG unchanged from previous. No\n sublingual nitrate given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\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: denies chest pain this morning, coughing occasional\n with associated burning chest pain. No SOB, no fevers/chills, anxious\n overnight, and had trouble sleeping\n Flowsheet Data as of 05:50 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: 36.8\nC (98.2\n HR: 85 (74 - 93) bpm\n BP: 104/61(71) {76/41(49) - 115/73(107)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75 kg (admission): 68 kg\n Total In:\n 660 mL\n 120 mL\n PO:\n 660 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///32/\n Physical Examination\n Sitting at edge of bed, NAD, A and O x 3\n HEENT- normocephalic, atraumatic\n CV\n RRR, S1, S2, no m,r,g. JVD at about 7 cm. PMI non-displaced\n Pulm- rales left base, otherwise CTA, improved from yesterday\n Abd- soft, NT, ND, active BS, no HSM\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No rash\n Neurologic: CNs II\n XII intact, ambulatory\n Labs / Radiology\n 171 K/uL\n 9.6 g/dL\n 101 mg/dL\n 6.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 35 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.6 %\n 7.8 K/uL\n [image002.jpg]\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n 03:49 AM\n WBC\n 8.0\n 7.0\n 9.4\n 7.8\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n 30.6\n Plt\n 167\n 139\n 151\n 171\n Cr\n 5.5\n 7.7\n 9.3\n 6.1\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n 101\n Other labs: PT / PTT / INR:12.6/28.6/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 67 y/o blind, deaf male w/ESRD, s/p cath on \n with stenting of distal LAD stenosis with continued to have chest pain\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with prximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient has continued to ask for nitroglycerin for chest\n pain overnight, including when he triggered this morning for same\n request. EKG's consistently unchanged. Unrelieved with maalox, GI\n cocktail. Trop 0.63 this morning. Was 0.97 at OSH. Elevated troponin\n may include component of CHF and renal failure, given flat CK.\n -Aspirin, plavix, imdur, metoprolol, lipitor; pt will likely need imdur\n upon d/c for angina/burning chest pain\n -added ACE inhibitor, BP stable\n -chest pain episodes yesterday resolved with SL NTG and then GI\n cocktail\n .\n # PUMP: Has known cardiomyopathy with EF 35% on Echo. No overt\n clinical signs of heart failure at this time. No peripheral edema,\n crackles, or JVD.\n -on ACEi\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, metoprolol\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%\n - pt no longer has O2 requirement after dialysis yesterday, pneumonia\n unlikely.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct stable\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> 1.5 liters removed yesterday during HD\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: full\n .\n DISPO: likely d/c today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2180-08-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 694674, "text": "Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments: Pt extubated with positive cuff leak. Placed on cool aerosol\n face tent and weaned down to Nasal Cannula. Will continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694678, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Continues to have episodes of burning chest pain - unable to score\n secondary to communication difficulty\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Pt eceived sl NTG 0.3mg x2 for CP\n pt verbalizing pain is gone; ECG\n during episode unchanged; 2^nd episode w\\relieved w/1 sl ntg; 2 units\n pRBC\ns given onnight shift\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear to few crackles at\n bases, RR 14-18; congested cough-expectorating thin dk blood-tinged\n secretions- now clearing; ABG with paO2 of 66, n/c increased to 4L\n w/sats consistently 100%, ABG repeat 7.44/35/98; BP remains stable off\n Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o ectopy; added\n lopressor 25mg \n received x 1 and tolerated well, Lisinopril 2.5mg\n added at 1800\n Chest pain responsive to sl NTG; Troponin level continues to trend\n down; Hct stable at 28\n Plan:\n Monitor vital signs and assess toleration to added meds; Assess pain\n sl NTG prn for burning chest pain; Follow CPK\ns and Troponin levels for\n repeat CP.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt communicates with ASL; able to verbally communicate needs fairly\n well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily to keep pt updated on condition, plan\n of care; on-call interpreter as needed.\n" }, { "category": "Respiratory ", "chartdate": "2180-08-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 694563, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\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: 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: Blood Tinged / 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: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=45. AM ABG 7.43/46/126/32\n Possible extubation today\n" }, { "category": "Nursing", "chartdate": "2180-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694743, "text": "Cardiac arrest\n Assessment:\n Hemodynamically stable with HR 80-90\ns NSR/ST, BP ranges\n 100-115/60-70\ns, oxygenating well on 4L n/c with only fine bibasilar\n rales, strong cough and expectorating well on his own, tolerating\n po\ns/meds, bilateral groin sites D/I, palp pulses, awake and alert,\n MAE, equally and strong, slept well in intervals\n Action:\n Tolerating restart of po cardiac meds, Lopressor/Lisinopril\n Response:\n Hemodynamically stable and painfree this shift\n Plan:\n Cont to monitor hemodynamics, assess response to cardiac meds, restart\n ER Isosorbide Mononitrate in am\n Problem\n Potential Ineffective Communication with Pt. due to his\n being blind and deaf\n Assessment:\n Pt. communicating his needs with words and hand gestures, able to\n understand his speech but at times it is difficult for him to\n understand us. Does not always answer our questions and at times it is\n hard to assess how well he understands all that is going on with his\n hospitalization. He is appreciative of care. He is asking appropriate\n questions about his heart and medication. He is most concerned about\n his girlfriend, .\n Action:\n Communicating with Pt. to meet his needs\n Response:\n Able to meet Pt\ns needs and provide comfort and emotional support\n Plan:\n Cont to address Pt\ns needs, ASL interpreter as needed to assist with\n communication. Reattempt to contact girlfriend, during the day.\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695022, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n - overnight patient tolerated cardiac meds, oob to chair &\n commode with 1 assist\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Patient with 2 cardiac cath\ns this admission (8/27&). Chest Pain\n free & hemodynamically stable.\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Patient awaiting PT consult prior to discharge. Mobility compromised by\n vision deficit as well as potentially by his hearing deficit. Visited\n by case manager & social worker prior shift to facilitate safe\n discharge plan including arrangement for medications.\n Action:\n o 1 assist from chair-bed-commode, patient calls appropriately\n for assistance, bed alarm maintained and call bell within reach.\n o Spoke into patient\ns right ear to maximize communication as\n patient with vision & hearing deficits\n Response:\n o Patient continues to call appropriately for assistance,\n occasionally sitting at edge of bed without calling for help first, but\n no attempts OOB.\n o Recommend using ASL translator for assisting with PT consult\n & discharge planning. Patient able to clearly state/verbalize his needs\n but noted overnight that he had difficulty understanding questions &\n explanations being offered to him- ASL interpreter hours posted in\n room.\n Plan:\n PT consult. Case management & social work involvement with discharge\n home- will have VNA. ASL interpreter as needed. Continue to maintain\n safety OOB and with activity.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694556, "text": "Cardiac arrest\n Assessment:\n Initially hemodynamically labile requiring titration of IV Dopamine\n 10-15mcg/kg/min with SBP 80\ns-90\ns/40\ns. HR initially 90-,\n bilateral groin sites stable\n Action:\n Additional peripheral IVs placed, including 18g for IV Dopamine, labs\n sent, started IV Fentanyl, arterial sheath pulled by cath lab RN,\n radial aline placed by CCU team, transfused with total of 2 units\n PRBCs, titrated IV Dopamine, monitored groin sites/pedal pulses ,\n serial abgs sent with vent changes, VAP protocol initiated,\n Response:\n Hct down to 24 from 30 post cath lab, improved to 28- after one unit,\n improved hemodynamics with PRBCs, able to wean IV Dopamine\n to stable serial abgs\n Plan:\n Cont to monitor hemodynamics, wean IV Dopamine as tolerated, follow up\n with am labs after 2^nd unit of PRBCs, Fentanyl/Versed for sedation,\n comfort, wean vent as tolerated,\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694666, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Continues to have episodes of burning chest pain - unable to score\n secondary to communication difficulty\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Pt eceived sl NTG 0.3mg x2 for CP\n pt verbalizing pain is gone; ECG\n during episode unchanged; 2^nd episode w\\relieved w/1 sl ntg\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear to few crackles at\n bases, RR 14-18; congested cough-expectorating thin dk blood-tinged\n secretions- now clearing; ABG with paO2 of 66, n/c increased to 4L\n w/sats consistently 100%; BP remains stable off Dopamine\n 105-120\ns/systolic; HR 90-100\ns SR-ST w/o ectopy; added lopressor 25mg\n \n received x 1 and tolerated well, Lisinopril 2.5mg added at 1800\n Chest pain responsive to sl NTG; Troponin level continues to trend down\n Plan:\n Monitor vital signs and assess toleration to added meds; Assess pain\n sl NTG prn for burning chest pain; Folow CPK\ns and Troponin levels for\n repeat CP.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt communicates with ASL; able to verbally communicate needs fairly\n well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily to keep pt updated on condition, plan\n of care; on-call interpreter as needed.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694667, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Continues to have episodes of burning chest pain - unable to score\n secondary to communication difficulty\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Pt eceived sl NTG 0.3mg x2 for CP\n pt verbalizing pain is gone; ECG\n during episode unchanged; 2^nd episode w\\relieved w/1 sl ntg\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear to few crackles at\n bases, RR 14-18; congested cough-expectorating thin dk blood-tinged\n secretions- now clearing; ABG with paO2 of 66, n/c increased to 4L\n w/sats consistently 100%, ABG repeat 7.45/35/98; BP remains stable off\n Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o ectopy; added\n lopressor 25mg \n received x 1 and tolerated well, Lisinopril 2.5mg\n added at 1800\n Chest pain responsive to sl NTG; Troponin level continues to trend down\n Plan:\n Monitor vital signs and assess toleration to added meds; Assess pain\n sl NTG prn for burning chest pain; Folow CPK\ns and Troponin levels for\n repeat CP.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt communicates with ASL; able to verbally communicate needs fairly\n well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily to keep pt updated on condition, plan\n of care; on-call interpreter as needed.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694668, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Continues to have episodes of burning chest pain - unable to score\n secondary to communication difficulty\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Pt eceived sl NTG 0.3mg x2 for CP\n pt verbalizing pain is gone; ECG\n during episode unchanged; 2^nd episode w\\relieved w/1 sl ntg\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear to few crackles at\n bases, RR 14-18; congested cough-expectorating thin dk blood-tinged\n secretions- now clearing; ABG with paO2 of 66, n/c increased to 4L\n w/sats consistently 100%, ABG repeat 7.44/35/98; BP remains stable off\n Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o ectopy; added\n lopressor 25mg \n received x 1 and tolerated well, Lisinopril 2.5mg\n added at 1800\n Chest pain responsive to sl NTG; Troponin level continues to trend down\n Plan:\n Monitor vital signs and assess toleration to added meds; Assess pain\n sl NTG prn for burning chest pain; Follow CPK\ns and Troponin levels for\n repeat CP.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt communicates with ASL; able to verbally communicate needs fairly\n well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily to keep pt updated on condition, plan\n of care; on-call interpreter as needed.\n" }, { "category": "Nursing", "chartdate": "2180-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694735, "text": "Cardiac arrest\n Assessment:\n Hemodynamically stable with HR 80-90\ns NSR/ST, BP ranges\n 100-115/60-70\ns, oxygenating well on 4L n/c with only fine bibasilar\n rales, strong cough and expectorating well on his own, tolerating\n po\ns/meds, bilateral groin sites D/I, palp pulses, awake and alert,\n MAE, equally and strong, slept well in intervals\n Action:\n Tolerating restart of po cardiac meds, Lopressor/Lisinopril\n Response:\n Hemodynamically stable and painfree this shift\n Plan:\n Cont to monitor hemodynamics, assess response to cardiac meds, restart\n ER Isosorbide Mononitrate in am\n Problem\n Potential Ineffective Communication with Pt. due to his\n being blind and deaf\n Assessment:\n Pt. communicating his needs with words and hand gestures, able to\n understand his speech but it is difficult for him to understand us.\n Does not always answer our questions and at times it is hard to assess\n how well he understands all that is going on with his hospitalization.\n He is asking appropriate questions about his heart and medication. He\n is most concerned about his girlfriend, .\n Action:\n Response:\n Plan:\n Cont to\n" }, { "category": "Physician ", "chartdate": "2180-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694736, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Extubated this AM- did well. Now off pressors. Had one episode of\n chest pain which required SL nitro. No EKG changes noted- pain\n resolved. Restarted imdur this PM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 08:08 AM\n Famotidine (Pepcid) - 08:45 AM\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 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 85 (85 - 111) bpm\n BP: 112/69(82) {96/36(63) - 117/73(83)} mmHg\n RR: 12 (11 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 1,134 mL\n PO:\n 240 mL\n TF:\n IVF:\n 377 mL\n Blood products:\n 397 mL\n Total out:\n 200 mL\n 0 mL\n Urine:\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 934 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 674 (674 - 674) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 2%\n PIP: 10 cmH2O\n SpO2: 97%\n ABG: 7.44/35/98.//0\n Ve: 7.5 L/min\n PaO2 / FiO2: 4,900\n Physical Examination\n GENERAL: Caucasian male. NAD\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 167 K/uL\n 9.7 g/dL\n 94 mg/dL\n 5.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.8 %\n 8.0 K/uL\n [image002.jpg]\n 07:30 PM\n 07:47 PM\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n WBC\n 7.7\n 8.0\n Hct\n 24.8\n 28.4\n 30\n 29.8\n 28.8\n Plt\n 153\n 167\n Cr\n 4.6\n 5.5\n TropT\n 0.50\n 0.65\n 0.56\n TCO2\n 31\n 31\n 32\n 31\n 24\n 25\n Glucose\n 140\n 94\n Other labs: CK / CKMB / Troponin-T:120/5/0.56, Lactic Acid:0.7 mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start low dose metoprolol when patient off of pressors\n -Hold home Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -EKG, ECHO in AM\n -Will add an ACE inhibitor when BP allows\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol when pressures stabilize off of\n pressors\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor when BP stable\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694841, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 104-120 map\ns > 70. pain free. Slight\n drop in o2 sats w sleep to 94%. O2 ^ from 2l-3l np w improving sats.\n Denies sob. C&R thick brown secretions. c/o sore throat ? etiology\n intubation vs dry mucosa.\n Action:\n ^ o2 via np. Cepacol loz given for c/o sore throat. Con\nt on Cardiac\n meds\n Response:\n No chg in VS. Cepacol w good effect. Hemodynamically stable\n Plan:\n Monitor VS, follow sats. Dialysis today. Likely c/o. ^ activity as\n tol.\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally speech\n garbled but baseline for pt. has hearing aid, but battery non\n functioning. Able to communicate effectively w pt thru lip \n approaching pt from R side. Pt is able to verbalize needs thru\n speech. ASL Interp. Available if needed.\n Action:\n Attempted to replace battery for hearing aid. No battery available in\n house and local pharmacy closed so unable to purchase.\n Response:\n Effective communication thru lip and gesturing.\n Plan:\n Notify pt\ns significant other to bring battery. Lip and\n gesturing. Patience and support.\n" }, { "category": "Social Work", "chartdate": "2180-08-28 00:00:00.000", "description": "Social Work Progress Note", "row_id": 694957, "text": "Social Work meets with pt. with ASL interpreter. Pt. has both auditory\n and visual impairments. SW asked to see pt. because RN has received\n message from pt\ns lawyer that pt\ns girlfriend may be misusing pt\n funds. Pt. denies, saying that she must ask him directly for money,\n has no independent access. Pt. indicates that girlfriend is an\n alcoholic but makes it clear that he is no danger from her. Pt.\n reports that girlfriend helps him with some household tasks but\n explains that he can do most things for himself and is not experiencing\n neglect. SW calls pt\ns lawyer, () to explore\n his concerns further and leaves message. Awaiting call back.\n Pt. is unaware of having Health Care Proxy. SW calls pt\ns PCP to\n ascertain and is awaiting return call.\n Pt. indicates that he would like to have a scooter to get to mailbox.\n Earlier SW note indicates that pt. has already been told that his low\n vision would make this impossible.\n Pt. is amenable to Medic bracelet and First system, though\n there is concern that this latter will not be suitable b/c of hearing\n impairment. SW contacts First to ascertain.\n Awaiting return call.\n Per note by , pt. has many services coming into home\n through Old Colony Elder Services as well as through Mass Commission\n for the . Pt. reports that he is also connected with Deaf Inc. SW\n contacts of Deaf Community Access Network, which\n is part of Deaf Inc. () to discuss and confirm. Awaiting\n return e-mail.\n SW will continue to follow prior to pt\ns anticipated discharge\n tomorrow.\n" }, { "category": "Physician ", "chartdate": "2180-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 695017, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt had episode of chest pain at end of dialysis session. Pt sat up, and\n was given sublingual nitrate which relieved pain. EKG was unchanged\n from prior. Pt also had all cardiac meds held because of hypotension\n earlier in the day. Given daily metoprolol, lisinopril, 90 of Imdur.\n Will likely need 120 of Imdur and toprol XL upon d/c, planned for\n tomorrow. Another episode of CP at 3:30 AM, sitting up c/o \"burning,\n relieved w/ GI cocktail, VSS, EKG unchanged from previous. No\n sublingual nitrate given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\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 05:50 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: 36.8\nC (98.2\n HR: 85 (74 - 93) bpm\n BP: 104/61(71) {76/41(49) - 115/73(107)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75 kg (admission): 68 kg\n Total In:\n 660 mL\n 120 mL\n PO:\n 660 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///32/\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 171 K/uL\n 9.6 g/dL\n 101 mg/dL\n 6.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 35 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.6 %\n 7.8 K/uL\n [image002.jpg]\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n 03:49 AM\n WBC\n 8.0\n 7.0\n 9.4\n 7.8\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n 30.6\n Plt\n 167\n 139\n 151\n 171\n Cr\n 5.5\n 7.7\n 9.3\n 6.1\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n 101\n Other labs: PT / PTT / INR:12.6/28.6/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 67 y/o blind, deaf male w/ESRD, s/p cath on \n with stenting of distal LAD stenosis with continued to have chest pain\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with prximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient has continued to ask for nitroglycerin for chest\n pain overnight, including when he triggered this morning for same\n request. EKG's consistently unchanged. Unrelieved with maalox, GI\n cocktail. Trop 0.63 this morning. Was 0.97 at OSH. Elevated troponin\n may include component of CHF and renal failure, given flat CK.\n -Consider re-cath this afternoon, following HD, if pain persisting. D1\n lesion could be treated at later time if continued ischemia.\n -Aspirin, plavix, imdur, metoprolol, lipitor\n -Continue to trend enzymes post LMCA dissection to evaluate\n -EKG, ECHO in AM\n -Will add an ACE inhibitor when BP allows\n .\n # PUMP: Has known cardiomyopathy with EF 35% on Echo. No overt\n clinical signs of heart failure at this time. No peripheral edema,\n crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol when pressures stabilize\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor when BP stable\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694658, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Continues to have episodes of burning chest pain - unable to score\n secondary to communication difficulty\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Received sl NTG 0.3mg x2\n pt verbalizing pain is gone; ECG during\n episode unchanged; 2^nd episode w\\relieved w/1 sl ntg\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear, RR 14-18;\n congested cough-expectorating thin dk blood-tinged secretions; ABG with\n paO2 of 66, n/c increased to 4L w/sats consistently 100%; BP remains\n stable off Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o ectopy;\n added lopressor 25mg \n received x 1 and tolerated well, Lisinopril\n also ordered\n Chest pain responsive to sl NTG; Troponin level continues to titrate\n down\n Plan:\n Monitor vital signs and assess toleration to added meds; Assess pain\n sl NTG prn for burning chest pain; Folow CPK\ns and Troponin levels for\n repeat CP.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt speaks ASL; able to verbalize needs fairly well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily; on-call interpreter as needed.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694660, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Continues to have episodes of burning chest pain - unable to score\n secondary to communication difficulty\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Received sl NTG 0.3mg x2\n pt verbalizing pain is gone; ECG during\n episode unchanged; 2^nd episode w\\relieved w/1 sl ntg\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear, RR 14-18;\n congested cough-expectorating thin dk blood-tinged secretions; ABG with\n paO2 of 66, n/c increased to 4L w/sats consistently 100%; BP remains\n stable off Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o ectopy;\n added lopressor 25mg \n received x 1 and tolerated well, Lisinopril\n also ordered\n Chest pain responsive to sl NTG; Troponin level continues to trend down\n Plan:\n Monitor vital signs and assess toleration to added meds; Assess pain\n sl NTG prn for burning chest pain; Folow CPK\ns and Troponin levels for\n repeat CP.\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt communicates with ASL; able to verbally communicate needs fairly\n well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily to keep pt updated on condition, plan\n of care; on-call interpreter as needed.\n" }, { "category": "Echo", "chartdate": "2180-08-26 00:00:00.000", "description": "Report", "row_id": 67182, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 190\nBSA (m2): 2.00 m2\nBP (mm Hg): 116/59\nHR (bpm): 120\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: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. No LV\nmass/thrombus. Moderately depressed LVEF. TDI E/e' >15, suggesting\nPCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta.\nMildly dilated aortic arch. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Moderate\n(2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. There is mild symmetric\nleft ventricular hypertrophy. The left ventricular cavity is moderately\ndilated. No masses or thrombi are seen in the left ventricle. Overall left\nventricular systolic function is moderately depressed (LVEF= 35 %) with global\nhypokinesis and akinesis of the infero-lateral and apical segments. Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). There is no ventricular septal defect. with mild global free\nwall hypokinesis. The aortic root is moderately dilated at the sinus level.\nThe ascending aorta is moderately dilated. The aortic arch is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild to moderate (+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nModerate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is moderate pulmonary artery systolic hypertension.\nThere is a trivial/physiologic pericardial effusion.\n\nCoompared to the prior study dated , no major change.\n\n\n" }, { "category": "Nursing", "chartdate": "2180-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694834, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694944, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n SP STENT TO LAD ,DIAG BALLOONED C/B Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 90S ,CARDIAC MEDS HELD PRE DIALYSIS\n . pain free. o2 sats 89 to 90 rm qir ,crackles and rhochi present ,c/r\n thick tan secretions.developed cp at end of dialysis ,p 90,bp 124\n systolic relieved c one sl nitro .\n Action:\n ^ o2 via np,dialysis this am,restarted cardiac meds\n Response:\n O2 sats improved c 02 ,bp improved during dialysis,cp relieved c one\n sl nitro\n Plan:\n Monitor VS, follow sats. Wean fio2 as toL, MONITOR FOR CP,l Increase\n activity AS TOL\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally\n ,hearingaid battery non functioning. Able to communicate effectively w\n pt thru lip approaching pt from R side\n Action:\n replaced battery for hearing aid. ALS INTERPRETER PRESENT DISCHARGE\n PANNING AND TEACHING DONE ,SEEN BY CASE MANAGEMENT,SOCIAL WoRKER ,p\n contact by social service\n Response:\n Effective communication C ASL INTERPRETER ,WILL HAVE VNA AND ELDER\n SERVICES. MEDS DELIVERED BY PHARMACY\n Plan:\n IN AM FAX REFERALS TO VNA AND PHARMACY,VERIFY THEY RECEIVED THEM AND\n MEDS WILL BE DELIVERED .CONTINUE DISCHARGE TEACHING AND PT \n WHEN ASL INTERPRETER PRESENT\n" }, { "category": "Physician ", "chartdate": "2180-08-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 695013, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt had episode of chest pain at end of dialysis session. Pt sat up, and\n was given sublingual nitrate which relieved pain. EKG was unchanged\n from prior. Pt also had all cardiac meds held because of hypotension\n earlier in the day. Given daily metoprolol, lisinopril, 90 of Imdur.\n Will likely need 120 of Imdur and toprol XL upon d/c, planned for\n tomorrow. Another episode of CP at 3:30 AM, sitting up c/o \"burning,\n relieved w/ GI cocktail, VSS, EKG unchanged from previous. No\n sublingual nitrate given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\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 05:50 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: 36.8\nC (98.2\n HR: 85 (74 - 93) bpm\n BP: 104/61(71) {76/41(49) - 115/73(107)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75 kg (admission): 68 kg\n Total In:\n 660 mL\n 120 mL\n PO:\n 660 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///32/\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 171 K/uL\n 9.6 g/dL\n 101 mg/dL\n 6.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 35 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.6 %\n 7.8 K/uL\n [image002.jpg]\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n 03:49 AM\n WBC\n 8.0\n 7.0\n 9.4\n 7.8\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n 30.6\n Plt\n 167\n 139\n 151\n 171\n Cr\n 5.5\n 7.7\n 9.3\n 6.1\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n 101\n Other labs: PT / PTT / INR:12.6/28.6/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n IMPAIRED PHYSICAL MOBILITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n INeffective Communication\n CARDIAC ARREST\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694630, "text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694631, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD s/p NSTEMI,\n cardiomyopathy with EF 35%; pt is also blind and deaf; initially\n admitted to OSH with chest pain radiating to shoulders treated with\n NTG, MSO4 - bumped troponin\n to for cath \n Pt was right\n dominant with diffuse CAD. LAD w/3 sequential stents placed in past\n which were widely patent; DES placed to LAD distal to these stents; 50%\n stenosis at the D1 level proximal to the stents w/o intervention; Pt\n was transferred to 3 and continued to have CP overnight; pt\n returned to cath lab after dialysis on ; Stent placed to D1 lesion\n and mid LAD lesion complicated by dissection\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694929, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n SP STENT TO LAD ,DIAG BALLOONED C/B Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 90S ,CARDIAC MEDS HELD PRE DIALYSIS\n . pain free. o2 sats 89 to 90 rm qir ,crackles and rhochi present ,c/r\n thick tan secretions.developed cp at end of dialysis ,p 90,bp 124\n systolic relieved c one sl nitro .\n Action:\n ^ o2 via np,dialysis this am,restarted cardiac meds\n Response:\n O2 sats improved c 02 ,bp improved during dialysis,cp relieved c one\n sl nitro\n Plan:\n Monitor VS, follow sats. Wean fio2 as toL, MONITOR FOR CP,l Increase\n activity AS TOL\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally\n ,hearingaid battery non functioning. Able to communicate effectively w\n pt thru lip approaching pt from R side\n Action:\n replaced battery for hearing aid. ALS INTERPRETER PRESENT DISCHARGE\n PANNING AND TEACHING DONE ,SEEN BY CASE MANAGEMENT,SOCIAL WoRKER ,p\n contact by social service\n Response:\n Effective communication C ASL INTERPRETER ,WILL HAVE VNA AND ELDER\n SERVICES. MEDS DELIVERED BY PHARMACY\n Plan:\n IN AM FAX REFERALS TO VNA AND PHARMACY,VERIFY THEY RECEIVED THEM AND\n MEDS WILL BE DELIVERED .CONTINUE DISCHARGE TEACHING AND PT \n WHEN ASL INTERPRETER PRESENT\n" }, { "category": "Physician ", "chartdate": "2180-08-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 694549, "text": "TITLE:\n Chief Complaint: Chest pain\n HPI:\n 67 year old blind, deaf man with ESRD, htn, CAD s/p NSTEMI,\n cardiomyopathy with EF 35%, initially admitted to hospital\n with burning chest pain radiating to shoulders. Ruled out for MI.\n Yesterday, patient returned to with burning chest pain radiating to\n his shoulder. No EKG changes, but known LBBB. Initial negative troponin\n negative, but afternoon trop elevated to 0.97. Overnight episodes of CP\n responded to 2 SL NTG +/- morphine. Continued to have episodes of CP\n responsive to NTG. Patient was transferred directly to cath lab\n on .\n .\n Coronary angiography on revealed a right dominant system with\n diffuse coronary artery disease. The LMCA was without angiographically\n apparent stenosis. The LAD had 3 sequencial stents that were widely\n patent. There was a 50% stenosis at the D1 level proximal to the\n stents. There was diffuse disease between the 2nd and 3rd stents with\n approximately 60% stenosis, and there was a 90% focal lesion just\n distal to the 3rd stent that was new since the prior catheterization in\n . The D1 had 90% proximal disease that was not apparently\n changed since prior. The LCX had a widely patent stent and no\n significant disease. The RCA had chronic subtotal occlusion in the\n mid-portion, with collaterals from the LAD distally. He had a\n successful PCI of the distal LAD with a DES which was post-dilated to\n 2.5mm. At this point the patient could not tolerate further\n intervention due to marked agitation, so it was\n elected not to intervene on the D1 lesion.\n .\n After this intervention the patient was transferred to 3 and\n continued to have chest pain on the floor. He continued to ask for\n nitroglycerin for chest pain overnight. EKGs were consistently\n unchanged. The pain was not relieved with a GI cocktail. Trop was 0.63,\n CK=53 on AM of and previously was trop=0.97 at OSH on . Due to\n his continued symptoms, he was taken to cath again on the afternoon of\n after his regularly scheduled HD session. The D1 lesion was\n successfully angioplastied and a successful PCI of prox/mid LAD with\n DES was performed, but the procedure was complicated by LMCA artery\n dissection. On the last final angiography injection, the LMCA was\n dissected, at which point the patient arrested. CPR was immmediately\n initiated and atropine was given. The Prowater wire was still in place\n in the LAD and a 3.5x28mm Xience DES was able to be delivered to the\n LMCA/prox LAD. This stent was post-dilated to 4.0 NC balloon with\n sealing of the dissection and restoration of TIMI 3 flow into the LAD\n and LCx. The patient left the lab intubated and on 5mcg/kg/min of\n dopamine to maintain a SBP of 100-110mmHg. Reportedly, his home SBP\n runs in the 90s-100s.\n .\n Upon transfer to the CCU the patient was sedated, intubated, and on\n dopamine to maintain his pressures. He had a peripheral line and\n femoral sheath for access. Initial blood gas was pH 7.53, pCO2 36, pO2\n 237, HCO3 31, BaseXS 7.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 8 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Lopressor 100 PO BID\n ASA 325 mg PO daily\n Zocor 40 mg PO daily\n Colace 100 mg PO daily\n Esomeprazole 40 mg PO daily\n Sevelamer 1600 mg PO with meals\n MVI PO daily\n Allopurinol 100 mg PO daily\n Cholecalciferol 400 units PO daily\n Amiodarone 200 mg PO daily\n Isosorbide mononitrate 120 mg PO daily\n Lorazepam 0.5 mg PO Q6 hrs PRN\n Oxazepam 10 PO QHS PRN\n Maalox 30 cc PO Q8 PRN\n Morphine Sulfate 2 mg IV Q4 hrs PRN\n Nitroglycerin 1 tab SL PRN\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY: Dilated Cardiomyopathy (EF 35%); NSTEMI , LAD\n stent in , cypher to OM3 with POBA to distal LCX in ;\n unsuccessful PTCA of RCA chronic total occlusion ; Paroxysmal\n atrial fibrillation\n 3. OTHER PAST MEDICAL HISTORY:\n ESRD w/ HD on MWF\n Gout\n Congenital deafness\n Retinitis pigmentosa\n Hypertension\n Speech deficit\n Peptic ulcer disease, dyspepsia\n Gout\n Osteoarthritis.\n Mother died of MI after age 80. Father died at 20's of an\n unspecified brain \"problem\". Other family history is not known\n by patient.\n He denies tobacco or alcohol use. He is currently unemployed on\n disability and lives with girlfriend\n Review of systems:\n Flowsheet Data as of 01:03 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: 37.7\nC (99.8\n HR: 100 (88 - 116) bpm\n BP: 102/55(66) {85/42(52) - 126/68(81)} mmHg\n RR: 16 (16 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 491 mL\n 169 mL\n PO:\n TF:\n IVF:\n 244 mL\n 40 mL\n Blood products:\n 188 mL\n 129 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 491 mL\n 169 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: 7.47/41/140/30/6\n Ve: 10.6 L/min\n PaO2 / FiO2: 350\n Physical Examination\n VS: T=99.7 BP=126/68 HR=103 RR=18 O2 sat=100% intubated\n GENERAL: Caucasian male, sedated, intubated.\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 153 K/uL\n 8.1 g/dL\n 140 mg/dL\n 4.6 mg/dL\n 27 mg/dL\n 30 mEq/L\n 100 mEq/L\n 4.0 mEq/L\n 139 mEq/L\n 24.8 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A8/28/ 07:30 PM\n \n 10:20 P8/28/ 07:47 PM\n \n 1:20 P8/28/ 11:08 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 24.8\n Plt\n 153\n Cr\n 4.6\n TropT\n 0.50\n TC02\n 31\n 31\n Glucose\n 140\n Other labs: CK / CKMB / Troponin-T:41//0.50, Lactic Acid:0.7 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start low dose metoprolol when patient off of pressors\n -Hold home Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -EKG, ECHO in AM\n -Will add an ACE inhibitor when BP allows\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol when pressures stabilize off of\n pressors\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor when BP stable\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694632, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear, RR 14-18;\n congested cough-expectorating thin dk blood-tinged secretions; BP\n remained stable off Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o\n ectopy\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694635, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n Cardiac arrest\n Assessment:\n tolerating extubation and subsequent rapid wean of Dopamine this AM\n Action:\n Fentanyl/Midazolam gtts D/C\nd and pt rapidly extubated at ~ 0830 to 70%\n face tent; BP improved to 120-130\ns/ immediately upon pt wakening\n Dopamine rapidly weaned from 5mcgs/kg/min to off at 0845\n Response:\n Oxygen weaned to 2L n/c with sats 100%, lungs clear, RR 14-18;\n congested cough-expectorating thin dk blood-tinged secretions; BP\n remained stable off Dopamine 105-120\ns/systolic; HR 90-100\ns SR-ST w/o\n ectopy\n Plan:\n Problem\n Potential Ineffective Communication with Patient\n Assessment:\n Difficult communication with patient secondary nearly blind and deaf;\n pt speaks ASL; able to verbalize needs fairly well\n Action:\n ASL interpreter visited, communicated with patient; pt wanted to call\n girlfriend ; RN left message on one of 2 phone numbers for\n , attempted other number-no answer; is also hearing\n impaired- ASL interpreter instructed RN for answering service\n interpretation for \n Response:\n Awaiting communication with \n :\n ASL interpreters will visit daily; on-call interpreter as needed.\n" }, { "category": "Nursing", "chartdate": "2180-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694707, "text": "Cardiac arrest\n Assessment:\n Hemodynamically stable with HR 80-90\ns NSR/ST, BP ranges\n 100-115/60-70\ns, oxygenating well on 4L n/c with only fine bibasilar\n rales, strong cough and expectorating well on his own, tolerating\n po\ns/meds, bilateral groin sites D/I, palp pulses, awake and alert,\n MAE, equally and strong, slept well in intervals\n Action:\n Tolerating restart of po cardiac meds, Lopressor/Lisinopril\n Response:\n Hemodynamically stable and\n Plan:\n Cont to monitor hemodynamics, assess response to cardiac meds, restart\n ER Isosorbide Mononitrate in am\n Problem\n Potential Ineffective Communication with Pt. due to\n blind and deaf\n Assessment:\n Pt. communicating his needs with words and hand gestures, able to\n understand his speech but it is difficult for him to understand us.\n Does not always answer our questions and at times it is hard to assess\n how well he understands all that is going on with his hospitalization.\n He is asking appropriate questions about his heart and medication. He\n is most concerned about his girlfriend, \n Action:\n Response:\n Plan:\n Cont to\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695005, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n - overnight patient tolerated cardiac meds, oob to chair &\n commode with 1 assist\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Patient awaiting PT consult prior to discharge. Mobility compromised by\n vision deficit as well as potentially by his hearing deficit.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 695103, "text": "Knowledge, Impaired\n Assessment\n Pt hoh and legally blind\n Action:\n Asl interpreter participated in discharge teaching, caritas vna\n notified of need for asl interpreter when seeing pt .\n Response:\n Pt has understanding of plan ,asking appropriate questions\n Plan:\n Discharge to home c vna,pt Thursday ,dialysis wenesday and followup\n appointment c dr \n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Sr no ect bp tol cardiac meds,no bleeding from cath sites , pulses palp\n Action:\n Ambulated c PT\n Response:\n Sat 95 rm air, no cp,bp stable\n Plan:\n DC TO HOME\n" }, { "category": "Physician ", "chartdate": "2180-08-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 694613, "text": "TITLE:\n Chief Complaint: Chest pain\n HPI:\n 67 year old blind, deaf man with ESRD, htn, CAD s/p NSTEMI,\n cardiomyopathy with EF 35%, initially admitted to hospital\n with burning chest pain radiating to shoulders. Ruled out for MI.\n Yesterday, patient returned to with burning chest pain radiating to\n his shoulder. No EKG changes, but known LBBB. Initial negative troponin\n negative, but afternoon trop elevated to 0.97. Overnight episodes of CP\n responded to 2 SL NTG +/- morphine. Continued to have episodes of CP\n responsive to NTG. Patient was transferred directly to cath lab\n on .\n .\n Coronary angiography on revealed a right dominant system with\n diffuse coronary artery disease. The LMCA was without angiographically\n apparent stenosis. The LAD had 3 sequencial stents that were widely\n patent. There was a 50% stenosis at the D1 level proximal to the\n stents. There was diffuse disease between the 2nd and 3rd stents with\n approximately 60% stenosis, and there was a 90% focal lesion just\n distal to the 3rd stent that was new since the prior catheterization in\n . The D1 had 90% proximal disease that was not apparently\n changed since prior. The LCX had a widely patent stent and no\n significant disease. The RCA had chronic subtotal occlusion in the\n mid-portion, with collaterals from the LAD distally. He had a\n successful PCI of the distal LAD with a DES which was post-dilated to\n 2.5mm. At this point the patient could not tolerate further\n intervention due to marked agitation, so it was\n elected not to intervene on the D1 lesion.\n .\n After this intervention the patient was transferred to 3 and\n continued to have chest pain on the floor. He continued to ask for\n nitroglycerin for chest pain overnight. EKGs were consistently\n unchanged. The pain was not relieved with a GI cocktail. Trop was 0.63,\n CK=53 on AM of and previously was trop=0.97 at OSH on . Due to\n his continued symptoms, he was taken to cath again on the afternoon of\n after his regularly scheduled HD session. The D1 lesion was\n successfully angioplastied and a successful PCI of prox/mid LAD with\n DES was performed, but the procedure was complicated by LMCA artery\n dissection. On the last final angiography injection, the LMCA was\n dissected, at which point the patient arrested. CPR was immmediately\n initiated and atropine was given. The Prowater wire was still in place\n in the LAD and a 3.5x28mm Xience DES was able to be delivered to the\n LMCA/prox LAD. This stent was post-dilated to 4.0 NC balloon with\n sealing of the dissection and restoration of TIMI 3 flow into the LAD\n and LCx. The patient left the lab intubated and on 5mcg/kg/min of\n dopamine to maintain a SBP of 100-110mmHg. Reportedly, his home SBP\n runs in the 90s-100s.\n .\n Upon transfer to the CCU the patient was sedated, intubated, and on\n dopamine to maintain his pressures. He had a peripheral line and\n femoral sheath for access. Initial blood gas was pH 7.53, pCO2 36, pO2\n 237, HCO3 31, BaseXS 7.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 8 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Lopressor 100 PO BID\n ASA 325 mg PO daily\n Zocor 40 mg PO daily\n Colace 100 mg PO daily\n Esomeprazole 40 mg PO daily\n Sevelamer 1600 mg PO with meals\n MVI PO daily\n Allopurinol 100 mg PO daily\n Cholecalciferol 400 units PO daily\n Amiodarone 200 mg PO daily\n Isosorbide mononitrate 120 mg PO daily\n Lorazepam 0.5 mg PO Q6 hrs PRN\n Oxazepam 10 PO QHS PRN\n Maalox 30 cc PO Q8 PRN\n Morphine Sulfate 2 mg IV Q4 hrs PRN\n Nitroglycerin 1 tab SL PRN\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY: Dilated Cardiomyopathy (EF 35%); NSTEMI , LAD\n stent in , cypher to OM3 with POBA to distal LCX in ;\n unsuccessful PTCA of RCA chronic total occlusion ; Paroxysmal\n atrial fibrillation\n 3. OTHER PAST MEDICAL HISTORY:\n ESRD w/ HD on MWF\n Gout\n Congenital deafness\n Retinitis pigmentosa\n Hypertension\n Speech deficit\n Peptic ulcer disease, dyspepsia\n Gout\n Osteoarthritis.\n Mother died of MI after age 80. Father died at 20's of an\n unspecified brain \"problem\". Other family history is not known\n by patient.\n He denies tobacco or alcohol use. He is currently unemployed on\n disability and lives with girlfriend\n Review of systems:\n Flowsheet Data as of 01:03 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: 37.7\nC (99.8\n HR: 100 (88 - 116) bpm\n BP: 102/55(66) {85/42(52) - 126/68(81)} mmHg\n RR: 16 (16 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 491 mL\n 169 mL\n PO:\n TF:\n IVF:\n 244 mL\n 40 mL\n Blood products:\n 188 mL\n 129 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 491 mL\n 169 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: 7.47/41/140/30/6\n Ve: 10.6 L/min\n PaO2 / FiO2: 350\n Physical Examination\n VS: T=99.7 BP=126/68 HR=103 RR=18 O2 sat=100% intubated\n GENERAL: Caucasian male, sedated, intubated.\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 153 K/uL\n 8.1 g/dL\n 140 mg/dL\n 4.6 mg/dL\n 27 mg/dL\n 30 mEq/L\n 100 mEq/L\n 4.0 mEq/L\n 139 mEq/L\n 24.8 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A8/28/ 07:30 PM\n \n 10:20 P8/28/ 07:47 PM\n \n 1:20 P8/28/ 11:08 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 24.8\n Plt\n 153\n Cr\n 4.6\n TropT\n 0.50\n TC02\n 31\n 31\n Glucose\n 140\n Other labs: CK / CKMB / Troponin-T:41//0.50, Lactic Acid:0.7 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start low dose metoprolol when patient off of pressors\n -Hold home Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -EKG, ECHO in AM\n -Will add an ACE inhibitor when BP allows\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol when pressures stabilize off of\n pressors\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor when BP stable\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2180-08-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 694615, "text": "TITLE:\n Chief Complaint: Chest pain\n HPI:\n 67 year old blind, deaf man with ESRD, htn, CAD s/p NSTEMI,\n cardiomyopathy with EF 35%, initially admitted to hospital\n with burning chest pain radiating to shoulders. Ruled out for MI.\n Yesterday, patient returned to with burning chest pain radiating to\n his shoulder. No EKG changes, but known LBBB. Initial negative troponin\n negative, but afternoon trop elevated to 0.97. Overnight episodes of CP\n responded to 2 SL NTG +/- morphine. Continued to have episodes of CP\n responsive to NTG. Patient was transferred directly to cath lab\n on .\n .\n Coronary angiography on revealed a right dominant system with\n diffuse coronary artery disease. The LMCA was without angiographically\n apparent stenosis. The LAD had 3 sequencial stents that were widely\n patent. There was a 50% stenosis at the D1 level proximal to the\n stents. There was diffuse disease between the 2nd and 3rd stents with\n approximately 60% stenosis, and there was a 90% focal lesion just\n distal to the 3rd stent that was new since the prior catheterization in\n . The D1 had 90% proximal disease that was not apparently\n changed since prior. The LCX had a widely patent stent and no\n significant disease. The RCA had chronic subtotal occlusion in the\n mid-portion, with collaterals from the LAD distally. He had a\n successful PCI of the distal LAD with a DES which was post-dilated to\n 2.5mm. At this point the patient could not tolerate further\n intervention due to marked agitation, so it was\n elected not to intervene on the D1 lesion.\n .\n After this intervention the patient was transferred to 3 and\n continued to have chest pain on the floor. He continued to ask for\n nitroglycerin for chest pain overnight. EKGs were consistently\n unchanged. The pain was not relieved with a GI cocktail. Trop was 0.63,\n CK=53 on AM of and previously was trop=0.97 at OSH on . Due to\n his continued symptoms, he was taken to cath again on the afternoon of\n after his regularly scheduled HD session. The D1 lesion was\n successfully angioplastied and a successful PCI of prox/mid LAD with\n DES was performed, but the procedure was complicated by LMCA artery\n dissection. On the last final angiography injection, the LMCA was\n dissected, at which point the patient arrested. CPR was immmediately\n initiated and atropine was given. The Prowater wire was still in place\n in the LAD and a 3.5x28mm Xience DES was able to be delivered to the\n LMCA/prox LAD. This stent was post-dilated to 4.0 NC balloon with\n sealing of the dissection and restoration of TIMI 3 flow into the LAD\n and LCx. The patient left the lab intubated and on 5mcg/kg/min of\n dopamine to maintain a SBP of 100-110mmHg. Reportedly, his home SBP\n runs in the 90s-100s.\n .\n Upon transfer to the CCU the patient was sedated, intubated, and on\n dopamine to maintain his pressures. He had a peripheral line and\n femoral sheath for access. Initial blood gas was pH 7.53, pCO2 36, pO2\n 237, HCO3 31, BaseXS 7.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 8 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Lopressor 100 PO BID\n ASA 325 mg PO daily\n Zocor 40 mg PO daily\n Colace 100 mg PO daily\n Esomeprazole 40 mg PO daily\n Sevelamer 1600 mg PO with meals\n MVI PO daily\n Allopurinol 100 mg PO daily\n Cholecalciferol 400 units PO daily\n Amiodarone 200 mg PO daily\n Isosorbide mononitrate 120 mg PO daily\n Lorazepam 0.5 mg PO Q6 hrs PRN\n Oxazepam 10 PO QHS PRN\n Maalox 30 cc PO Q8 PRN\n Morphine Sulfate 2 mg IV Q4 hrs PRN\n Nitroglycerin 1 tab SL PRN\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY: Dilated Cardiomyopathy (EF 35%); NSTEMI , LAD\n stent in , cypher to OM3 with POBA to distal LCX in ;\n unsuccessful PTCA of RCA chronic total occlusion ; Paroxysmal\n atrial fibrillation\n 3. OTHER PAST MEDICAL HISTORY:\n ESRD w/ HD on MWF\n Gout\n Congenital deafness\n Retinitis pigmentosa\n Hypertension\n Speech deficit\n Peptic ulcer disease, dyspepsia\n Gout\n Osteoarthritis.\n Mother died of MI after age 80. Father died at 20's of an\n unspecified brain \"problem\". Other family history is not known\n by patient.\n He denies tobacco or alcohol use. He is currently unemployed on\n disability and lives with girlfriend\n Review of systems:\n Flowsheet Data as of 01:03 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: 37.7\nC (99.8\n HR: 100 (88 - 116) bpm\n BP: 102/55(66) {85/42(52) - 126/68(81)} mmHg\n RR: 16 (16 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 491 mL\n 169 mL\n PO:\n TF:\n IVF:\n 244 mL\n 40 mL\n Blood products:\n 188 mL\n 129 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 491 mL\n 169 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: 7.47/41/140/30/6\n Ve: 10.6 L/min\n PaO2 / FiO2: 350\n Physical Examination\n VS: T=99.7 BP=126/68 HR=103 RR=18 O2 sat=100% intubated\n GENERAL: Caucasian male, sedated, intubated.\n HEENT: NCAT. Sclera anicteric. PERRL.\n NECK: Supple with no JVD\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with\n temporary HD cath site clean, intact.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Has bowel sounds in all four quadrants.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No rashes\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 153 K/uL\n 8.1 g/dL\n 140 mg/dL\n 4.6 mg/dL\n 27 mg/dL\n 30 mEq/L\n 100 mEq/L\n 4.0 mEq/L\n 139 mEq/L\n 24.8 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A8/28/ 07:30 PM\n \n 10:20 P8/28/ 07:47 PM\n \n 1:20 P8/28/ 11:08 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 24.8\n Plt\n 153\n Cr\n 4.6\n TropT\n 0.50\n TC02\n 31\n 31\n Glucose\n 140\n Other labs: CK / CKMB / Troponin-T:41//0.50, Lactic Acid:0.7 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -Start low dose metoprolol when patient off of pressors\n -Hold home Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -EKG, ECHO in AM\n -Will add an ACE inhibitor when BP allows\n .\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol when pressures stabilize off of\n pressors\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor when BP stable\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Presumed full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\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). from .\n I would add the following remarks:\n History\n Agree with above, nothing to add\n Physical Examination\n Agree with above, nothing to add\n Medical Decision Making\n Agree with above, nothing to add\n Total time spent on patient care: 80 minutes of critical care time.\n Additional comments:\n intubated, cardiac arrest, left main dissection\n ------ Protected Section Addendum Entered By: ,MD\n on: 08:49 ------\n" }, { "category": "Nursing", "chartdate": "2180-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694913, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n SP STENT TO LAD ,DIAG BALLOONED C/B Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 90S ,CARDIAC MEDS HELD PRE DIALYSIS\n . pain free. o2 sats 89 to 90 rm qir ,crackles and rhochi present ,c/r\n thick tan secretions\n Action:\n ^ o2 via np,dialysis this am\n Response:\n O2 sats improved c 02 ,bp improved during dialysis\n Plan:\n Monitor VS, follow sats. Wean fio2 as tol,ambulate c pt, give\n antihypertensives post dialysis\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally\n ,hearingaid battery non functioning. Able to communicate effectively w\n pt thru lip approaching pt from R side\n Action:\n replaced battery for hearing aid. ALS INTERPRETER PRESENT DISCHARGE\n PANNING AND TEACHING DONE ,SEEN BY CASE MANAGEMENT,SOCIAL OWRKER\n Response:\n Effective communication C ALS INTERPRETER ,WILL HAVE VNA AND ELDER\n SERVICES.\n Plan:\n Notify pt\ns significant other to bring battery. Lip and\n gesturing. Patience and support.\n" }, { "category": "Physician ", "chartdate": "2180-08-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 695231, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt had episode of chest pain at end of dialysis session. Pt sat up, and\n was given sublingual nitrate which relieved pain. EKG was unchanged\n from prior. Pt also had all cardiac meds held because of hypotension\n earlier in the day. Given daily metoprolol, lisinopril, 90 of Imdur.\n Will likely need 120 of Imdur and toprol XL upon d/c, planned for\n tomorrow. Another episode of CP at 3:30 AM, sitting up c/o \"burning,\n relieved w/ GI cocktail, VSS, EKG unchanged from previous. No\n sublingual nitrate given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\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: denies chest pain this morning, coughing occasional\n with associated burning chest pain. No SOB, no fevers/chills, anxious\n overnight, and had trouble sleeping\n Flowsheet Data as of 05:50 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: 36.8\nC (98.2\n HR: 85 (74 - 93) bpm\n BP: 104/61(71) {76/41(49) - 115/73(107)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75 kg (admission): 68 kg\n Total In:\n 660 mL\n 120 mL\n PO:\n 660 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///32/\n Physical Examination\n Sitting at edge of bed, NAD, A and O x 3\n HEENT- normocephalic, atraumatic\n CV\n RRR, S1, S2, no m,r,g. JVD at about 7 cm. PMI non-displaced\n Pulm- rales left base, otherwise CTA, improved from yesterday\n Abd- soft, NT, ND, active BS, no HSM\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No rash\n Neurologic: CNs II\n XII intact, ambulatory\n Labs / Radiology\n 171 K/uL\n 9.6 g/dL\n 101 mg/dL\n 6.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 35 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.6 %\n 7.8 K/uL\n [image002.jpg]\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n 03:49 AM\n WBC\n 8.0\n 7.0\n 9.4\n 7.8\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n 30.6\n Plt\n 167\n 139\n 151\n 171\n Cr\n 5.5\n 7.7\n 9.3\n 6.1\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n 101\n Other labs: PT / PTT / INR:12.6/28.6/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.3 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 67 y/o blind, deaf male w/ESRD, s/p cath on \n with stenting of distal LAD stenosis with continued to have chest pain\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with prximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient has continued to ask for nitroglycerin for chest\n pain overnight, including when he triggered this morning for same\n request. EKG's consistently unchanged. Unrelieved with maalox, GI\n cocktail. Trop 0.63 this morning. Was 0.97 at OSH. Elevated troponin\n may include component of CHF and renal failure, given flat CK.\n -Aspirin, plavix, imdur, metoprolol, lipitor; pt will likely need imdur\n upon d/c for angina/burning chest pain\n -added ACE inhibitor, BP stable\n -chest pain episodes yesterday resolved with SL NTG and then GI\n cocktail\n .\n # PUMP: Has known cardiomyopathy with EF 35% on Echo. No overt\n clinical signs of heart failure at this time. No peripheral edema,\n crackles, or JVD.\n -on ACEi\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, metoprolol\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%\n - pt no longer has O2 requirement after dialysis yesterday, pneumonia\n unlikely.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed.\n -Hct stable\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> 1.5 liters removed yesterday during HD\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg IV\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: full\n .\n DISPO: likely d/c today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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 would add the following remarks:\n History\n Nothing to add\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 60 minutes.\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:35 ------\n" }, { "category": "Physician ", "chartdate": "2180-08-25 00:00:00.000", "description": "Cardiology fellow addendum", "row_id": 694533, "text": "TITLE: Cardiology fellow addendum\n 67 yo with ESRD, CAD, s/p distal LAD stenting yesterday, today returned\n to lab for mid LAD and D1 stenting, developed LMCA dissection. Then\n became asystolic and had 5 minutes of CPR and 1x epi, intubated. LMCA\n was stented, dopamine was started with SBP 90-110. Pt did not require\n IABP. There was apparently quick return of BP. Currently pt is without\n pulmonary edema but continues to require dopamine due to vasodilating\n meds (propofol) and positive pressure ventilation.\n Plan to continue ventilation tonight, dopamine as required, and\n extubate tomorrow. No more IVF, given ESRD. Cont ASA and Plavix as\n planned.\n Sheath will be pulled tonight.\n" }, { "category": "Nursing", "chartdate": "2180-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694535, "text": "PT C LONG CARDIAC HX SP STENT TO LAD BUT HAD CP ALL NIGHT ,\n RETURNED TO CATH LAB TODAY LAD RESTENTED ,BALLOONED DIAG AND THEN\n SUFFERED DISSECTION OF L MAIN ,CARDIAC ARREST ,CPR,INTUBATION,\n ATROPINE ,DOPAMINE WIDE OPEN ,DOWN TIME 5MIN .L MAIN STENTED .PT IS\n BLIND AND DEAF\n Cardiac arrest\n Assessment:\n PT ARRIVED FROM CATH LAB BP TRANSIENTLY LOW BUT STABLIZED BY TITRATING\n DOPAMINE .ST NO ECTOPY . NP BLEEING FROM CaTH SITES,DISTAL PUSES BY\n DOPPLER .VENTED 0N 100%. PT ,RESPONDED TO SX BY MOVING\n EXTREMITIES ,PUPILS EQUAL AND REACTIVE\n Action:\n WEANING DOPAMINE AS TOL.MAINTAINING SEDATION . MONITORING FOR BLEEDING\n Response:\n VSS CURRENTLY STABLE ON 10 MIC DOPAMINE ,NO BLEEDING\n Plan:\n CONTINUE TO WEAN DOPAMINE ,PT TO BE INTUBATED OVER NIGHT ,REPLACE PTS\n HEARING AID TO COMMUNICATE C PT\n" }, { "category": "Nursing", "chartdate": "2180-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694530, "text": "Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694585, "text": "Cardiac arrest\n Assessment:\n Initially hemodynamically labile requiring titration of IV Dopamine\n 10-15mcg/kg/min with SBP 80\ns-90\ns/40\ns. HR initially 90-,\n bilateral groin sites stable, Intubated and mechanically ventilated on\n A/C, sedated but episode of acute agitation when RIBI by RT, sitting\n bolt up right, thrashing head side to side, eyes open, pulling at soft\n wrist restraints, MAE, equally and strong. Pt. is deaf and blind-unable\n to effectively communicate with Pt.\n Action:\n Additional peripheral IVs placed, including 18g for IV Dopamine after\n discussed with CCU team need for central access, labs sent, started IV\n Fentanyl, arterial sheath pulled by cath lab RN, radial aline placed by\n CCU team, transfused with total of 2 units PRBCs, titrated IV Dopamine,\n monitored groin sites/pedal pulses , serial abgs sent with vent\n changes, VAP protocol initiated,\n Response:\n Hct down to 24.8 from 30.9 post cath lab, groin sites D/I without palp.\n Hematoma, Hct to 28.4- after one unit, improved hemodynamics with\n PRBCs, SBP 90\nS-110\nS/50, HR 80-90\ns NSR, able to wean IV Dopamine to\n 5mcg/kg/min , stable serial abgs sedated on Fent./Versed requiring\n bolus for acute agitation\n Plan:\n Cont to monitor hemodynamics, wean IV Dopamine as tolerated, follow up\n with am labs after 2^nd unit of PRBCs, Fentanyl/Versed for sedation,\n comfort, wean vent as tolerated, and will need to determine means of\n communication with POC.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694587, "text": "Cardiac arrest\n Assessment:\n Initially hemodynamically labile requiring titration of IV Dopamine\n 10-15mcg/kg/min with SBP 80\ns-90\ns/40\ns. HR initially 90-,\n bilateral groin sites stable, Intubated and mechanically ventilated on\n A/C, sedated but episode of acute agitation when performing RIBI by RT,\n sitting bolt up right, thrashing head side to side, eyes open, pulling\n at soft wrist restraints, MAE, equally and strong. Pt. is deaf and\n blind-unable to effectively communicate with Pt.\n Action:\n Additional peripheral IVs placed, including 18g for IV Dopamine after\n discussed with CCU team need for central access, labs sent, started IV\n Fentanyl, arterial sheath pulled by cath lab RN, radial aline placed by\n CCU team, transfused with total of 2 units PRBCs, titrated IV Dopamine,\n monitored groin sites/pedal pulses , serial abgs sent with vent\n changes, VAP protocol initiated,\n Response:\n Hct down to 24.8 from 30.9 post cath lab, groin sites D/I without palp.\n Hematoma, Hct to 28.4- after one unit, improved hemodynamics with\n PRBCs, SBP 90\nS-110\nS/50, HR 80-90\ns NSR, able to wean IV Dopamine to\n 5mcg/kg/min , stable serial abgs sedated on Fent./Versed requiring\n bolus for acute agitation episode with RISBI\n Plan:\n Cont to monitor hemodynamics, wean IV Dopamine as tolerated, follow up\n with am labs after 2^nd unit of PRBCs, Fentanyl/Versed for sedation,\n comfort, wean vent as tolerated, and will need to determine means of\n communication with POC.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694591, "text": "Cardiac arrest\n Assessment:\n Initially hemodynamically labile requiring titration of IV Dopamine\n 10-15mcg/kg/min with SBP 80\ns-90\ns/40\ns. HR initially 90-,\n bilateral groin sites stable, Intubated and mechanically ventilated on\n A/C, sedated but episode of acute agitation when performing RIBI by RT,\n sitting bolt up right, thrashing head side to side, eyes open, pulling\n at soft wrist restraints, MAE, equally and strong. Pt. is deaf and\n blind-unable to effectively communicate with Pt.\n Action:\n Additional peripheral IVs placed, including 18g for IV Dopamine after\n discussed with CCU team need for central access, labs sent, started IV\n Fentanyl, arterial sheath pulled by cath lab RN, radial aline placed by\n CCU team, transfused with total of 2 units PRBCs, titrated IV Dopamine,\n monitored groin sites/pedal pulses , serial abgs sent with vent\n changes, VAP protocol initiated,\n Response:\n Hct down to 24.8 from 30.9 post cath lab, groin sites D/I without palp.\n Hematoma, Hct to 28.4-29.8 after two units, improved hemodynamics with\n PRBCs, SBP 90\nS-110\nS/50, HR 80-90\ns NSR, able to wean IV Dopamine to\n 5mcg/kg/min , stable serial abgs sedated on Fent./Versed requiring\n bolus for acute agitation episode with RISBI\n Plan:\n Cont to monitor hemodynamics, wean IV Dopamine as tolerated, follow up\n with am labs, Fentanyl/Versed for sedation, comfort, wean vent as\n tolerated, and will need to determine means of communication with POC.\n" }, { "category": "Nursing", "chartdate": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694595, "text": "Cardiac arrest\n Assessment:\n Initially hemodynamically labile requiring titration of IV Dopamine\n 10-15mcg/kg/min with SBP 80\ns-90\ns/40\ns. HR initially 90-,\n bilateral groin sites stable, Intubated and mechanically ventilated on\n A/C, sedated but episode of acute agitation when performing RIBI by RT,\n sitting bolt up right, thrashing head side to side, eyes open, pulling\n at soft wrist restraints, MAE, equally and strong. Pt. is deaf and\n blind-unable to effectively communicate with Pt.\n Action:\n Additional peripheral IVs placed, including 18g for IV Dopamine after\n discussed with CCU team need for central access, labs sent, started IV\n Fentanyl, arterial sheath pulled by cath lab RN, radial aline placed by\n CCU team, transfused with total of 2 units PRBCs, titrated IV Dopamine,\n monitored groin sites/pedal pulses , serial abgs sent with vent\n changes, VAP protocol initiated,\n Response:\n Hct down to 24.8 from 30.9 post cath lab, groin sites D/I without\n palphematoma, Hct to 28.4-29.8 after two units, improved hemodynamics\n with PRBCs, SBP 90\nS-110\nS/50, HR 80-90\ns NSR, able to wean IV Dopamine\n to 5mcg/kg/min , stable serial abgs sedated on Fent./Versed requiring\n bolus\n for acute agitation episode with RISBI\n Plan:\n Cont to monitor hemodynamics, wean IV Dopamine as tolerated, follow up\n with am labs, follow Hcts Fentanyl/Versed for sedation, comfort, wean\n vent as tolerated, and will need to determine means of communication\n with POC.\n" }, { "category": "Nursing", "chartdate": "2180-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694812, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac arrest\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2180-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694815, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n Cardiac arrest\n Assessment:\n Hemodynamically stable with HR 80-90\ns NSR/ST, BP ranges 100\ns O2 sat\n 100% on 2ln/p w/ some crackles at bases. Strong, productive cough.\n Bilateral groin sites D/I, palp pulses, awake and , , equally\n and strong, slept well in intervals\n Action:\n Administered Lopressor, lisinopril and Imdur as ordered. Pt OOB to\n chair w/ supervision/1 assist.\n Response:\n BP down to upper 80\ns post am meds. Feeling good OOB, but tired.\n Plan:\n Cont to monitor hemodynamics, assess response to cardiac meds, plan for\n HD in AM.\n Problem\n Potential Ineffective Communication with Pt. due to his\n being blind and deaf\n Assessment:\n Pt. communicating his needs with words and hand gestures, able to\n understand his speech but at times it is difficult for him to\n understand us. Does not always answer our questions and at times it is\n hard to assess how well he understands all that is going on with his\n hospitalization.\n Action:\n ASL interpreter visited today and assisted w/ MD \n communication. Attempted to call pt\ns girlfriend , but no\n answer.\n Response:\n Able to meet Pt\ns needs and provide comfort and emotional support.\n Plan:\n Cont to address Pt\ns needs, ASL interpreter as needed to assist with\n communication.\n" }, { "category": "Respiratory ", "chartdate": "2180-08-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 694524, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 64 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Diagnostic lab\n Reason: Emergent (1st time); Comments: Arrested in cath lab\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: 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: Bloody / 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: 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 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 Pt in Cardiac Cath lab undergoing a cath and ARRESTED and required\n intubation. BP low and labile, and was HD unstable\n T/ferred to the CCU and has improved a little with pressors.\n, RRT 18:35\n" }, { "category": "Physician ", "chartdate": "2180-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694870, "text": "Chief Complaint: chest pain\n 24 Hour Events:\n no overnight events\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:12 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 Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n productive green/yellow sputum\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: Dialysis\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:33 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: 36.2\nC (97.2\n HR: 78 (76 - 87) bpm\n BP: 104/64(73) {80/29(44) - 117/72(82)} mmHg\n RR: 20 (11 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Diaphoretic,\n mildly diaphoretic\n Eyes / Conjunctiva: PERRL, EOMi\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : bibasilar, Bronchial: right posterior lung,\n Rhonchorous: right posterior lung)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 9.2 g/dL\n 87 mg/dL\n 9.3 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 67 mg/dL\n 95 mEq/L\n 136 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n WBC\n 8.0\n 7.0\n 9.4\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n Plt\n 167\n 139\n 151\n Cr\n 5.5\n 7.7\n 9.3\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 31\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n Other labs: PT / PTT / INR:12.9/26.9/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.1 mg/dL, Mg++:3.5\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -cont metoprolol 25mg PO BID\n -cont Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -lisinopril 2.5mg daily -> will hold anti-hypertensives pre-dialysis\n given low SBP 80s\n .\n # cough/sputum production: concern for hospital-acquired PNA, although\n pt afebrile\n - will consider PA/lateral, defer empiric therapy for now\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol yesterday\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> appreciate input, will check PTH\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694873, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n SP STENT TO LAD ,DIAG BALLOONED C/B Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 90S ,CARDIAC MEDS HELD PRE DIALYSIS\n . pain free. Slight drop in o2 sats w sleep to 94%. O2 ^ from 2l-3l np\n w improving sats. Denies sob. C&R thick brown secretions. c/o sore\n throat ? etiology intubation vs dry mucosa.\n Action:\n ^ o2 via np. Cepacol loz given for c/o sore throat. Con\nt on Cardiac\n meds\n Response:\n No chg in VS. Cepacol w good effect. Hemodynamically stable\n Plan:\n Monitor VS, follow sats. Dialysis today. Likely c/o. ^ activity as\n tol.\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally speech\n garbled but baseline for pt. has hearing aid, but battery non\n functioning. Able to communicate effectively w pt thru lip \n approaching pt from R side. Pt is able to verbalize needs thru\n speech. ASL Interp. Available if needed.\n Action:\n Attempted to replace battery for hearing aid. No battery available in\n house and local pharmacy closed so unable to purchase.\n Response:\n Effective communication thru lip and gesturing.\n Plan:\n Notify pt\ns significant other to bring battery. Lip and\n gesturing. Patience and support.\n" }, { "category": "Nursing", "chartdate": "2180-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 694892, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n SP STENT TO LAD ,DIAG BALLOONED C/B Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 90S ,CARDIAC MEDS HELD PRE DIALYSIS\n . pain free. Slight drop in o2 sats w sleep to 94%. O2 ^ from 2l-3l np\n w improving sats. Denies sob. C&R thick brown secretions. c/o sore\n throat ? etiology intubation vs dry mucosa.\n Action:\n ^ o2 via np. Cepacol loz given for c/o sore throat. Con\nt on Cardiac\n meds\n Response:\n No chg in VS. Cepacol w good effect. Hemodynamically stable\n Plan:\n Monitor VS, follow sats. Dialysis today. Likely c/o. ^ activity as\n tol.\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally speech\n garbled but baseline for pt. has hearing aid, but battery non\n functioning. Able to communicate effectively w pt thru lip \n approaching pt from R side. Pt is able to verbalize needs thru\n speech. ASL Interp. Available if needed.\n Action:\n Attempted to replace battery for hearing aid. No battery available in\n house and local pharmacy closed so unable to purchase.\n Response:\n Effective communication thru lip and gesturing.\n Plan:\n Notify pt\ns significant other to bring battery. Lip and\n gesturing. Patience and support.\n" }, { "category": "Physician ", "chartdate": "2180-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694893, "text": "Chief Complaint: chest pain\n 24 Hour Events:\n no overnight events\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:12 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 Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n productive green/yellow sputum\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: Dialysis\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:33 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: 36.2\nC (97.2\n HR: 78 (76 - 87) bpm\n BP: 104/64(73) {80/29(44) - 117/72(82)} mmHg\n RR: 20 (11 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Diaphoretic,\n mildly diaphoretic\n Eyes / Conjunctiva: PERRL, EOMi\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : bibasilar, Bronchial: right posterior lung,\n Rhonchorous: right posterior lung)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 9.2 g/dL\n 87 mg/dL\n 9.3 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 67 mg/dL\n 95 mEq/L\n 136 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n WBC\n 8.0\n 7.0\n 9.4\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n Plt\n 167\n 139\n 151\n Cr\n 5.5\n 7.7\n 9.3\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 31\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n Other labs: PT / PTT / INR:12.9/26.9/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.1 mg/dL, Mg++:3.5\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -cont metoprolol 25mg PO BID\n -cont Imdur\n -Continue to trend enzymes post LMCA dissection and cardiac arrest to\n evaluate extent of heart damage\n -lisinopril 2.5mg daily -> will hold anti-hypertensives pre-dialysis\n given low SBP 80s\n .\n # cough/sputum production: concern for hospital-acquired PNA, although\n pt afebrile\n - will consider PA/lateral, defer empiric therapy for now\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -Will add an ACE inhibitor when BP allows\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, start metoprolol yesterday\n .\n # Hypotension: Currently on dopamine given peripherally with goal to\n maintain pressures above 90s-100s systolic\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code. Continue\n Versed/Fentanyl as needed for sedation on vent. Patient can likely be\n extubated tomorrow morning as vent settings are on assist control with\n Tidal volume=500 cc, Respiratory rate: 18, PEEP: 5 cm/h2o, FIO2: 50%.\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> appreciate input, will check PTH\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Full\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\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 would add the following remarks:\n History\n Nothing to add, will insert line (groin) today\n Physical Examination\n Nothing to add,\n Medical Decision Making\n Nothing to add,\n Total time spent on patient care: 50 minutes.\n ------ Protected Section ------\n The groin will be checked today (correction to above teaching note\n history)\n ------ Protected Section Addendum Entered By: ,MD\n on: 10:46 AM ------\n" }, { "category": "Physician ", "chartdate": "2180-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694902, "text": "Chief Complaint: chest pain\n 24 Hour Events:\n no overnight events\n no chest pain for > 48 hours; does have cough productive of green\n sputum, denies dyspnea, fevers, or chills\n no other complaints\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:12 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n productive green/yellow sputum\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: Dialysis\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:33 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: 36.2\nC (97.2\n HR: 78 (76 - 87) bpm\n BP: 104/64(73) {80/29(44) - 117/72(82)} mmHg\n RR: 20 (11 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Diaphoretic,\n mildly diaphoretic\n Eyes / Conjunctiva: PERRL, EOMi\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : bibasilar, Bronchial: right posterior lung)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 9.2 g/dL\n 87 mg/dL\n 9.3 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 67 mg/dL\n 95 mEq/L\n 136 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n WBC\n 8.0\n 7.0\n 9.4\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n Plt\n 167\n 139\n 151\n Cr\n 5.5\n 7.7\n 9.3\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 31\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n Other labs: PT / PTT / INR:12.9/26.9/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.1 mg/dL, Mg++:3.5\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n Assessment and Plan\n 67 y/o blind, deaf male w/ESRD, s/p cath on with stenting of\n distal LAD stenosis. Patient had continued chest pain and was again\n taken to cath which was complicated by LMCA dissection and cardiac\n arrest.\n .\n # CORONARIES: Cath : LAD w/ 3 sequential stents widely patient. 50%\n lesion at D1 proximal to stents. 60% diffuse disease between 2nd and\n 3rd stents; 90% focal lesion just distal to 3rd stent (new since ).\n D1 with proximal 90% disease (unchanged). New stent placed over distal\n LAD lesion. Procedure stopped prematurely secondary to patient\n agitation. Patient continued to have chest pain requiring nitroglycerin\n for chest pain overnight, EKG's consistently unchanged. Unrelieved with\n maalox, GI cocktail. Trop 0.63 morning of . Was 0.97 at OSH. The\n patient underwent a second cath with successful angioplasty to the D1\n and successful PCI of prox/mid LAD with DES. This procedure was\n complicated by LMCA dissection which caused cardiac arrest requiring\n CPR, atropine, and intubation. The LMCA dissection was corrected by\n LMCA stenting.\n -Continue Aspirin, plavix, lipitor\n -cont metoprolol 25mg PO BID\n -discontinue Imdur\n -lisinopril 2.5mg daily -> will hold anti-hypertensives pre-dialysis\n given SBP 90s to 100s\n .\n # cough/sputum production: concern for hospital-acquired PNA, although\n pt afebrile; no white count, but trending up\n - defer empiric therapy for now\n - if patient still has O2 requirement post-dialysis today, consider PA\n and lateral chest film and empiric antibiotic treatment of HAP\n # PUMP: Has known ischemic cardiomyopathy with EF 35% on Echo. No\n overt clinical signs of heart failure at this time. No peripheral\n edema, crackles, or JVD.\n -added ACE inhibitor\n .\n # RHYTHM: Paroxysmal atrial fibrillation. Sinus rhythm today.\n -C/w amiodarone, metoprolol\n .\n # Hypotension: Initially managed with dopamine given peripherally with\n goal to maintain pressures above 90s-100s systolic, now off dopa, doing\n well\n -C/w metoprolol, ACE inhibitor\n .\n # Hypoxia: Patient intubated and sedated following code.\n Versed/Fentanyl was needed for sedation on vent. Patient now extubated\n .\n # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure\n which is out of proportion to what would be an expected blood loss from\n cath. Concern for retroperitoneal bleed. Hct up to 27.6 this AM\n -Hct checks q8h\n -Will transfuse 1 unit of pRBCs and monitor post transfusion Hct\n -Premedicate with Tylenol 1 gram and Benadryl 25mg IV as patient has\n low grade temperature of 99.7\n -Hct continues to normalize\n .\n # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning\n prior to cath.\n -C/w Nephrocaps, renagel\n -F/u renal recs -> appreciate input, will check PTH\n .\n # Gout\n -C/w allopurinol\n .\n # Congenital deafness: Can read lips effectively at baseline. Will\n involve ASL interpreters as needed when patient extubated.\n .\n # Peptic ulcer disease, dyspepsia: Famotidine for now.\n .\n FEN: NPO for now, consider OG tube feeds if not extubated tomorrow\n .\n ACCESS: PIV, HD cath\n .\n PROPHYLAXIS:\n -Famotidine 20mg PO\n -DVT ppx with SC heparin\n -Bowel regimen with docusate\n .\n CODE: Full\n .\n DISPO: possible d/c today if no O2 requirement post-dialysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 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": "2180-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694584, "text": "Cardiac arrest\n Assessment:\n Initially hemodynamically labile requiring titration of IV Dopamine\n 10-15mcg/kg/min with SBP 80\ns-90\ns/40\ns. HR initially 90-,\n bilateral groin sites stable, Intubated and mechanically ventilated on\n A/C, sedated but episode of acute agitation when RIBI by RT, sitting\n bolt up right, thrashing head side to side, eyes open, pulling at soft\n wrist restraints, MAE, equally and strong.\n Action:\n Additional peripheral IVs placed, including 18g for IV Dopamine after\n discussed with CCU team need for central access, labs sent, started IV\n Fentanyl, arterial sheath pulled by cath lab RN, radial aline placed by\n CCU team, transfused with total of 2 units PRBCs, titrated IV Dopamine,\n monitored groin sites/pedal pulses , serial abgs sent with vent\n changes, VAP protocol initiated,\n Response:\n Hct down to 24 from 30 post cath lab, groin sites D/I without palp.\n Hematoma, Hct to 28- after one unit, improved hemodynamics with PRBCs,\n able to wean IV Dopamine to 5mcg/kg/min , stable serial abgs sedated on\n Fent./Versed\n Plan:\n Cont to monitor hemodynamics, wean IV Dopamine as tolerated, follow up\n with am labs after 2^nd unit of PRBCs, Fentanyl/Versed for sedation,\n comfort, wean vent as tolerated,\n" }, { "category": "Nursing", "chartdate": "2180-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694863, "text": "Pt is a 67 year old man with ESRD (HD M-W-F), HTN, CAD w/interventions\n in past, s/p NSTEMI, cardiomyopathy with EF 35%; pt is also blind and\n deaf; initially admitted to OSH with chest pain radiating to shoulders\n treated with NTG, MSO4 - bumped troponin\n to for cath \n cath showed right dominant system with diffuse CAD. LAD w/3\n sequential stents placed in past which were widely patent; DES placed\n to LAD distal to these stents; 50% stenosis at the D1 level proximal to\n the stents w/o intervention; Pt was transferred to 3 and continued\n to have CP overnight; pt returned to cath lab after dialysis on ;\n PCI to D1 lesion and DES to mid LAD lesion complicated by dissection\n of LMCA and cardiac arrest; pt received brief CPR, Intubated, stent to\n LMCA and transferred to CCU Intubated on Dopamine gtt.\n rec\nd 2uprbc\ns for hct 24.8. Sedation weaned and pt was quickly\n extubated and dopa weaned.\n - 7p-7a oob to chair, ambulating c supervision @ chg of shift.\n VSS, pain free\n Cardiac arrest\n Assessment:\n Remains in nsr w hr 70-80\ns. sbp 104-120 map\ns > 70. pain free. Slight\n drop in o2 sats w sleep to 94%. O2 ^ from 2l-3l np w improving sats.\n Denies sob. C&R thick brown secretions. c/o sore throat ? etiology\n intubation vs dry mucosa.\n Action:\n ^ o2 via np. Cepacol loz given for c/o sore throat. Con\nt on Cardiac\n meds\n Response:\n No chg in VS. Cepacol w good effect. Hemodynamically stable\n Plan:\n Monitor VS, follow sats. Dialysis today. Likely c/o. ^ activity as\n tol.\n Problem\n Potential Ineffective Communication d/t Pt Legally\n blind/deaf\n Assessment:\n Pt deaf/blind. some peripheral vision. Communicates verbally speech\n garbled but baseline for pt. has hearing aid, but battery non\n functioning. Able to communicate effectively w pt thru lip \n approaching pt from R side. Pt is able to verbalize needs thru\n speech. ASL Interp. Available if needed.\n Action:\n Attempted to replace battery for hearing aid. No battery available in\n house and local pharmacy closed so unable to purchase.\n Response:\n Effective communication thru lip and gesturing.\n Plan:\n Notify pt\ns significant other to bring battery. Lip and\n gesturing. Patience and support.\n ------ Protected Section ------\n 06:15 sbp 98-104. lopressor 25mg held this am after discussion with\n house staff and renal. Is due for dialysis today. Had drop in bp on\n after receiving cardiac meds. Hr 80 nsr. Oob chair this am.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:41 ------\n" }, { "category": "Physician ", "chartdate": "2180-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 694868, "text": "Chief Complaint: chest pain\n 24 Hour Events:\n no overnight events\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:12 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 Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n productive green/yellow sputum\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: Dialysis\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:33 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: 36.2\nC (97.2\n HR: 78 (76 - 87) bpm\n BP: 104/64(73) {80/29(44) - 117/72(82)} mmHg\n RR: 20 (11 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 68 kg\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Diaphoretic,\n mildly diaphoretic\n Eyes / Conjunctiva: PERRL, EOMi\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : bibasilar, Bronchial: right posterior lung,\n Rhonchorous: right posterior lung)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 9.2 g/dL\n 87 mg/dL\n 9.3 mg/dL\n 25 mEq/L\n 5.3 mEq/L\n 67 mg/dL\n 95 mEq/L\n 136 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 11:08 PM\n 01:43 AM\n 01:51 AM\n 05:25 AM\n 05:49 AM\n 01:56 PM\n 01:58 PM\n 05:25 PM\n 06:10 AM\n 05:48 AM\n WBC\n 8.0\n 7.0\n 9.4\n Hct\n 28.4\n 30\n 29.8\n 28.8\n 27.6\n 30.1\n Plt\n 167\n 139\n 151\n Cr\n 5.5\n 7.7\n 9.3\n TropT\n 0.65\n 0.56\n 0.70\n TCO2\n 31\n 32\n 31\n 24\n 25\n Glucose\n 94\n 77\n 87\n Other labs: PT / PTT / INR:12.9/26.9/1.1, CK / CKMB /\n Troponin-T:160/7/0.70, Lactic Acid:0.7 mmol/L, Ca++:8.1 mg/dL, Mg++:3.5\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n INeffective Communication\n CARDIAC ARREST\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 06:30 PM\n 20 Gauge - 08:00 PM\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "ECG", "chartdate": "2180-08-25 00:00:00.000", "description": "Report", "row_id": 143609, "text": "Sinus rhythm. Compared to the previous tracing no change.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2180-08-25 00:00:00.000", "description": "Report", "row_id": 143610, "text": "Sinus rhythm. Left ventricular hypertrophy. Intraventricular conduction\ndelay. Compared to the previous tracing no change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2180-08-24 00:00:00.000", "description": "Report", "row_id": 143611, "text": "Sinus rhythm. Left ventricular hypertrophy. Intraventricular conduction\ndelay. Compared to the previous tracing no change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2180-08-24 00:00:00.000", "description": "Report", "row_id": 143612, "text": "Sinus rhythm. Left ventricular hypertrophy. Intraventricular conduction\ndelay. Compared to the previous tracing no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2180-08-24 00:00:00.000", "description": "Report", "row_id": 143613, "text": "Sinus rhythm. Possible left ventricular hypertrophy. Intraventricular\nconduction delay. Compared to the previous tracing of no change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2180-08-29 00:00:00.000", "description": "Report", "row_id": 143605, "text": "Sinus rhythm. Baseline artifact. Borderline P-R interval prolongation. Consider\nleft atrial abnormality. Intraventricular conduction delay. ST-T wave\nabnormalities. Since the previous tracing of the rate has decreased.\n\n" }, { "category": "ECG", "chartdate": "2180-08-26 00:00:00.000", "description": "Report", "row_id": 143606, "text": "Sinus tachycardia. Left bundle-branch block. Compared to the previous tracing\nthere is no change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2180-08-25 00:00:00.000", "description": "Report", "row_id": 143607, "text": "Sinus tachycardia. Left bundle-branch block. Compared to the previous tracing\nthe rate has increased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2180-08-25 00:00:00.000", "description": "Report", "row_id": 143608, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof there is no change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2180-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095488, "text": " 7:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube placement\n Admitting Diagnosis: MYOCARDIAL INFARCTION;CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new OG tube.\n REASON FOR THIS EXAMINATION:\n chest tube placement\n ______________________________________________________________________________\n WET READ: MBue FRI 9:21 PM\n CARDIOMEGALY WITH PULMONARY VASCULAR CONGESTION AND SMALL BILATERAL PLEURAL\n EFFUSIONS. ET TUBE TERMINATES 4.5 CM ABOVE CARINA. OG TUBE TERMINATES IN\n STOMACH. ? HIATAL HERNIA. A LATERAL VIEW BE HELPFUL. RT CVC UNCHANGED IN\n POSITION.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: OG tube placement.\n\n FINDINGS: In comparison with the study of , the patient has taken a much\n better inspiration. Persistent enlargement of the cardiac silhouette with\n evidence of elevated pulmonary venous pressure and small bilateral pleural\n effusions. The endotracheal tube tip lies approximately 4.5 cm above the\n carina. OG tube extends into the stomach, though the side hole is in the\n region of the esophagogastric junction. Right central catheter position is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095538, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post extubation\n Admitting Diagnosis: MYOCARDIAL INFARCTION;CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with LMCA dissection s/p code blue yesterday\n REASON FOR THIS EXAMINATION:\n post extubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Vascular dissection with code blue, following extubation.\n\n FINDINGS: In comparison with study of , the nasogastric tube has been\n pushed forward slightly so that the side hole appears to extend beyond the\n esophagogastric junction. Endotracheal tube has been removed. Progressive\n improvement in pulmonary vascular status.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2102-06-09 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1142595, "text": " 9:52 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Eval for evid of \n Admitting Diagnosis: PERFORATED BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with nausea/vomiting\n REASON FOR THIS EXAMINATION:\n Eval for evid of \n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 12:49 PM\n Nonspecific non-obstructive bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old woman with nausea and vomiting. Evaluate for\n evidence of obstruction.\n\n COMPARISON: None.\n\n SUPINE AND ERECT ABDOMINAL RADIOGRAPH: Nonspecific non-obstructive bowel gas\n pattern is noted. Surgical clips are seen extending along the left abdomen.\n Fixation hardware is seen projecting from L3 to L5. No free air is noted.\n\n IMPRESSION: Nonspecific non-obstructive bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2102-06-09 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1142596, "text": ", CC6A 9:52 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Eval for evid of \n Admitting Diagnosis: PERFORATED BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with nausea/vomiting\n REASON FOR THIS EXAMINATION:\n Eval for evid of \n ______________________________________________________________________________\n PFI REPORT\n Nonspecific non-obstructive bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2102-06-10 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1142724, "text": " 2:08 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abdominal collection\n Admitting Diagnosis: PERFORATED BOWEL\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with WBC post op\n REASON FOR THIS EXAMINATION:\n abdominal collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SAT 6:37 AM\n 1. Presacral fluid collection, with mild rim enhancement, concerning for an\n early abscess.\n 2. No bowel obstruction.\n Updated wetread d/w Dr. .\n WET READ VERSION #1 ENYa SAT 5:42 AM\n No intra-abdominal abscess. No bowel obstruction, free air or fluid.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman, with leukocytosis, status post sigmoid colectomy\n for perforated diverticulitis. Assess for intra-abdominal abscess.\n\n COMPARISON: CT abdomen and pelvis on .\n\n TECHNIQUE: MDCT images were acquired from the lung bases to the pubic\n symphysis after administration of oral and IV contrast. Multiplanar\n reformatted images were obtained for evaluation.\n\n CT ABDOMEN WITH CONTRAST: Bibasilar atelectasis is mild in the visualized\n lung bases. There is no pleural effusion. There is a sizable hiatal hernia\n with food content in the sac.\n\n The liver is normal without focal lesions. This patient is status post\n cholecystectomy with clips in the empty gallbladder fossa. There is interval\n decrease of the previous CBD dilatation. The spleen, pancreas, adrenal glands\n are normal. A 12-mm partly exophytic left lower pole renal cyst is noted\n (image 4:30). Other bilateral renal cysts are subcentimeter, too small to be\n fully evaluated, but statistically likely to be simple renal cysts. There is\n prompt excretion of IV contrast into the collecting system bilaterally. The\n stomach, duodenum and loops of small bowel are grossly unremarkable. There is\n no free air, fluid or lymphadenopathy in the abdomen.\n\n CT PELVIS WITH CONTRAST: In the pre-sacral area, there is an intermediate\n attenuating fluid collection, with rim enhancement, measuring 20 x 82 mm\n (image 4:66), compatible with an abscess. The patient is status post sigmoid\n colectomy, with suture line noted in the rectal vault. The patient also has a\n colostomy site at the left lower quadrant. There is no bowel obstruction.\n There is expected fat stranding in the recent post-surgical site.\n\n A 8 x 3 mm tiny pocket of mixed gas and fluid is seen underneath the soft\n tissue beneath the incision site, non-specific, could represent resolving\n (Over)\n\n 2:08 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abdominal collection\n Admitting Diagnosis: PERFORATED BOWEL\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hematoma or tiny abscess. Small nodes are likely reactive.\n\n Moderate vascular calcifications are noted in the descending aorta and its\n major branches.\n\n BONE WINDOW: There are no suspicious lytic or sclerotic lesions. Posterior\n spinal fixation hardware is again noted at L3, 4 and 5 level.\n\n IMPRESSION: A moderate-sized fluid collection in the pre-sacral area, with\n rim enhancement, compatible with abscess. This abscess may be amenable for\n image-guided drainage.\n\n The findings have been discussed with Dr. at 6:37AM on the day of\n the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1141393, "text": " 5:59 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Line postion, PTX\n Admitting Diagnosis: PERFORATED BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with new R IJ CVL\n REASON FOR THIS EXAMINATION:\n Line postion, PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with new right IJ central venous line, position of\n the line and pneumothorax evaluation.\n\n TECHNIQUE: Portable supine chest radiograph, single view.\n\n COMPARISON: Compared to chest radiograph, .\n\n FINDINGS: Lungs are hyperinflated, with evidence of emphysema. There is a\n small opacity at the right apex, likely ateoectasis. There is a new right IJ\n in place, with tip at the lower SVC, upper right atrium. There is no\n pneumothorax. Bibasilar opacities, likely representing atelectasis. Stable\n small left pleural effusion. Hilar, mediastinal, and cardiac silhouette are\n within normal limits. Atherosclerotic changes seen at the aortic arch. There\n is NG tube in place, with tip below GE junction, likely in the stomach.\n\n IMPRESSION:\n 1. New right IJ in place with tip at the right upper atrium. No\n pneumothorax.\n\n 2. Bibasilar opacities at the lung bases, worse on the left, could be\n atelectasis. Stable small left pleural effusion.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-01 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1141357, "text": " 8:53 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: ABD PAIN, DIFFUSED TENDERNESS. EVAL\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with abdominal pain and diffuse tenderness\n REASON FOR THIS EXAMINATION:\n r/o mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:54 PM\n Trace abd free fluid, some free air.\n Atheromatous aortic dz, mild stenosis, but no evidence of occlusion.\n Colonic diverticulosis, otherwise unremarkable bowel loops. ?mild stranding\n in pelvis\n Fibroid uterus.\n WET READ VERSION #1 10:14 PM\n Atheromatous aortic dz, but no evidence of mesenteric occlusion or ischemia.\n Colonic diverticulosis, otherwise nl bowel loops. Trace abd free fluid, no\n free air. Fibroid uterus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female with diffuse abdominal pain.\n\n COMPARISON: CTA chest from and MRCP from .\n\n TECHNIQUE: Multiplasic CT of the abdomen and pelvis including noncontrast,\n arterial and venous plase imaging. Multiplanar reformats provided.\n\n FINDINGS:\n LUNG BASES: There has been interval enlargement of large paraesophageal\n hiatal hernia, with retained air and fluid contents. Moderate emphysema is\n seen at the lung bases. There are peripheral fibrotic changes, suggestive of\n interstitial lung disease. Some bibasilar atelectasis is also present. There\n are no pleural or pericardial effusions. Calcifications are present in the\n aortic valve and left anterior descending coronary artery.\n\n ABDOMEN: A collection of free air is noted anterior to the liver, and\n outlining bowel loops in the right upper quadrant. At the root of the\n mesentery, a few locules of gas are also present, along with a small amount of\n simple fluid collection and minimal soft tissue stranding. Trace free fluid\n is also noted tracking into the perisplenic region, bilateral paracolic\n gutters, and pelvis.\n\n The stomach and small bowel are unremarkable. Colonic diverticulosis is noted\n without definite evidence of diverticilis. There is no bowel dilation to\n suggest obstruction. No abnormal wall thickening, enhancement, pneumatosis,\n or mesenteric or portal venous gas to suggest bowel ischemia.\n\n The liver enhances homogeneously, without focal masses. Stable intrahepatic\n biliary dilatation is noted, secondary to prior cholecystectomy. There is\n moderate atrophy of the pancreas, with scattered cystic-appearing lesions that\n (Over)\n\n 8:53 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: ABD PAIN, DIFFUSED TENDERNESS. EVAL\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are consistent with known IPMN. The spleen is unremarkable.\n\n The adrenals are normal. The kidneys are slightly atrophic with cortical\n thinning and lobulation. However, contrast enhancement and excretion are\n preserved. A 1.5-cm simple cyst is present in the left renal interpole.\n Other scattered renal hypodensities are too small to characterize.\n\n PELVIS: Multiple calcified fibroids are present in the uterus. The bladder\n is normal. Moderate atheromatous disease is noted in the abdominal aorta and\n iliac arteries, with dense calcifications and irregular soft plaques. There\n is mild-to-moderate stenosis of branch artery origins, but distal perfusion is\n preserved. Retroperitoneal and mesenteric lymph nodes are not pathologically\n enlarged.\n\n There is diffuse osseous demineralization and degenerative changes of the\n thoracolumbar spine, most severe at L1-L2. Grade 1 retrolisthesis is present\n at L4-5. Posterior fusion hardware is present in the L3-L5 vertebral ,\n without evidence of hardware loosening, fragmentation, or other complications.\n\n IMPRESSION:\n 1. Pneumoperitoneum without clear etiology, small free fluid. Diverticulosis,\n with no clear evidence of diverticulitis. Findings discussed with Dr. at\n 10:50 p.m.\n 2. Atheromatous disease, without evidence of mesenteric ischemia.\n 3. Large hiatal hernia.\n\n" }, { "category": "Radiology", "chartdate": "2102-06-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1141359, "text": " 9:06 PM\n CHEST (PA & LAT) Clip # \n Reason: evidence of free air?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with diffuse abdominal pain\n REASON FOR THIS EXAMINATION:\n evidence of free air?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: .\n\n CLINICAL HISTORY: Diffuse abdominal pain, question free air.\n\n FINDINGS: PA and lateral views of the chest were obtained. The patient is\n significantly rotated to her left which limits the evaluation. There is\n bibasilar opacity which could represent atelectasis, though at the left lung\n base, the possibility of pneumonia is not excluded. A retrocardiac gas-filled\n structure is again noted compatible with a hiatal hernia. Along the right\n hemidiaphragm, a linear density with underlying lucency could reflect\n platelike atelectasis though the possibility of pneumoperitoneum is\n considered.\n\n IMPRESSION: Limited study with bibasilar opacities, likely atelectasis.\n Limited evaluation for pneumoperitoneum. Please refer to subsequent CT\n abdomen for additional findings.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2102-06-11 00:00:00.000", "description": "DRAINAGE HEMATOMA/FLUID", "row_id": 1142899, "text": " 11:32 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDANCE DRAINAGE Clip # \n MOD SEDATION, FIRST 30 MIN.; MOD SEDATION, EACH ADDL 15 MIN.\n Reason: intrabd fluid collection\n Admitting Diagnosis: PERFORATED BOWEL\n ********************************* CPT Codes ********************************\n * DRAINAGE HEMATOMA/FLUID CT GUIDANCE DRAINAGE *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 F s/p exlap sigmoid resection, now w/ fluid collection in abd\n REASON FOR THIS EXAMINATION:\n intrabd fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old female status post exploratory laparotomy and sigmoid\n resection for perforated diverticulitis and Hartmann's procedure, with pelvic\n fluid collection, presenting for CT-guided drainage and catheter placement.\n\n COMPARISON: CT of the abdomen and pelvis dated .\n\n PROCEDURE/FINDINGS: Preprocedure non-contrast axial images of the pelvis\n obtained with the patient in the left decubitus position demonstrate\n persistent fluid collection in the pelvis, measuring approximately 7 x 2 cm,\n not significantly changed. A calcified fibroid is observed and post-operative\n changes.\n\n After discussing the benefits, alternatives and risks of the procedure,\n written informed consent was obtained. A preprocedure timeout was performed,\n using three patient identifiers. The patient was brought into the CT suite,\n and positioned on the CT table in the left decubitus position, then prepped\n and draped in usual sterile fashion. Local anesthesia was achieved with 1%\n lidocaine solution. An 18-gauge needle was placed percutaneously into\n the pelvic fluid collection under the CT guidance. A 2 cc sample was obtained\n for the purpose of microbiology analysis. A Bentson guidewire was then passed\n through the needle into the fluid collection. Using serial dilators,\n the tract was dilated and an 8 French pigtail catheter was then placed\n into the collection over the guidewire. The guidewire was removed. CT\n fluoroscopy confirmed satisfactory position within the collection. 30 cc of\n cloudy sanguinous fluid was aspirated. A drainage bag was attached. The\n catheter was secured to the overlying skin with a statlock device. A sterile\n dressing was applied.\n\n The patient tolerated procedure well, with no immediate complications. Dr.\n , the attending radiologist, was present and supervising\n throughout the procedure.\n\n Moderate sedation was provided by administrating divided doses of fentanyl and\n Versed. The total intraservice time was 55 minutes, during which the\n patient's hemodynamic parameters were continuously monitored.\n\n (Over)\n\n 11:32 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDANCE DRAINAGE Clip # \n MOD SEDATION, FIRST 30 MIN.; MOD SEDATION, EACH ADDL 15 MIN.\n Reason: intrabd fluid collection\n Admitting Diagnosis: PERFORATED BOWEL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Technically successful CT-guided insertion of an 8 French \n pigtail catheter into the pelvic fluid collection. Sample fluid sent for Gram\n stain and culture as requested. Post-procedure instructions were entered into\n the provider order entry system.\n\n" }, { "category": "ECG", "chartdate": "2102-06-01 00:00:00.000", "description": "Report", "row_id": 259563, "text": "Sinus rhythm at upper limits of normal rate. Compared to the previous tracing\na small R wave is now visible in lead aVF. Findings are otherwise similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2102-06-01 00:00:00.000", "description": "Report", "row_id": 259564, "text": "Sinus rhythm. Possible inferior wall myocardial infarction, age indeterminate.\nExtensive baseline artifact. RSR' pattern in lead VI is probably a normal\nvariant. Early precordial lead transition. Compared to the previous tracing\nof findings are similar.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2179-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837274, "text": " 12:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Question of effusion on left.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with symptoms of CHF and left sided crackles on exam\n REASON FOR THIS EXAMINATION:\n Question of effusion on left.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of crackles on auscultation. Evaluate for left effusion.\n\n PORTABLE AP CHEST X-RAY: Comparison is made to study from ____/04.\n Polychamber cardiomegaly is again noted. There is opacification of the left\n costophrenic angle, suggestive of pleural effusion, which is unchanged from\n previous exam. No right pleural effusion is seen. There is increased\n prominence of the pulmonary vasculature, which represents mild CHF. Patient\n is status post sternotomy. A pacemaker is seen overlying the left hemithorax\n with leads unchanged in position from previous exam. No pneumothorax is seen.\n\n IMPRESSION: Left effusion is seen and unchanged from previous exam. Mild CHF\n is noted.\n\n" }, { "category": "Radiology", "chartdate": "2179-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837401, "text": " 8:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement s/p swan\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with symptoms of CHF and left sided crackles on exam\n\n REASON FOR THIS EXAMINATION:\n line placement s/p swan\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n CHEST, AP PORTABLE: Comparison is made to a study obtained earlier on the\n same day.\n\n Polychamber cardiomegaly is again noted. Interval placement of a swan ganz\n catheter with its tip in the right interlobar artery. Again noted is\n opacification of the left costophrenic angle. There are several pleural\n effusions, which are unchanged since the prior study. There is prominence of\n the pulmonary vasculature, representing mild left ventricular failure.\n\n IMPRESSION\n\n 1. No pneumothorax.\n 2. Good position of the swan ganz catheter.\n 3. Mild left ventricular failure.\n\n" }, { "category": "Radiology", "chartdate": "2179-07-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837844, "text": " 4:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for triple lumen placement s/p change over from swa\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with symptoms of CHF s/p line change over a wire\n REASON FOR THIS EXAMINATION:\n evaluate for triple lumen placement s/p change over from swan\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: CV line placement.\n\n Right jugular CV line is in distal SVC. No pneumothorax. S/P CABG. Marked\n cardiomegaly with bilateral pleural effusions and upper zone redistribution as\n previously demonstrated. Atelectasis in left lower lobe. Left sided ICD.\n\n" }, { "category": "Radiology", "chartdate": "2179-07-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837664, "text": " 8:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with symptoms of CHF and left sided crackles on exam\n\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, left sided crackles.\n\n PORTABLE SEMI-UPRIGHT AP CHEST: Comparison is made with . There is\n stable, dramatic polychamber cardiomegaly. The appearance of the dual chamber\n pacemaker overlying the left anterior chest wall is unchanged. The right\n internal jugular approach Swan-Ganz catheter tip is in the right main\n pulmonary artery. Sternal wires and multiple clips are unchanged. There is\n worsening pulmonary edema, particularly in the left perihilar area. There is\n a small bilateral pleural effusion. There is worsening left lower lobe\n atelectasis.\n\n IMPRESSION: Worsening CHF.\n\n\n" }, { "category": "Echo", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 66947, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 70\nWeight (lb): 158\nBSA (m2): 1.89 m2\nBP (mm Hg): 905/8\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:47\nTest: 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 markedly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is markedly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is severely dilated. There is an apical left ventricular\naneurysm. Overall left ventricular systolic function is severely depressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Severe (4+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Moderate to severe\n[3+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant pulmonic regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is markedly dilated.\nLeft ventricular wall thicknesses are normal except the septum which is\nthinned. The left ventricular cavity is severely dilated. There is akinesis of\nthe septum. The is a posterior apical aneurysm. There is hypokinesis of the\nremaining walls with some preservation of the basal lateral and inferolateral\nwalls. Overall left ventricular systolic function is severely depressed\n(ejection fraction 10%). A left apical thrombus cannot be fully excluded. The\nright ventricular cavity is dilated. The basal segment of the right\nventricular contracts. The aortic valve leaflets (3) are mildly thickened but\nnot stenotic. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Severe (4+) mitral regurgitation is seen. Moderate to severe\n[3+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. Mild to moderate pulmonic regurgitation is seen. There\nis no pericardial effusion.\n\nCompared to the prior study of (tape not available for review), there\nhas been a small increase in the pulmonary artery systolic pressures. The\nposterior apical aneurysm was not previously described.\n\n\n" }, { "category": "ECG", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 146132, "text": "Reversed L-R arm lead\nAtrial mechanism uncertain - appears to be atrial fibrillation\nIntermittent ventricular paced beats\nRight bundle branch block\nLeft axis deviation - left anterior fascicular block\nAnterolateral myocardial infarct, age indeterminate\nClinical correlation is suggested\nSince previous tracing of , L-R arm lead reversed\n\n" }, { "category": "ECG", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 146133, "text": "Atrial mechanism uncertain - appears to be atrial fibrillation\nIntermittent ventricular paced beats\nRight bundle branch block\nLeft axis deviation - left anterior fascicular block\nAnterolateral myocardial infarct, age indeterminate\nClinical correlation is suggested\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 146134, "text": "Baseline artifact\nVentricular paced rhythm with pattern of ventricular fusion complexes\nAtrial mechanism uncertain - may also be atrial pacing but baseline artifact\nmakes assessment difficult\nClinical correlation is suggested\nSince previous tracing of , probably no significant change but baseline\nartifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2179-07-25 00:00:00.000", "description": "Report", "row_id": 146135, "text": "A-V sequential pacing\n\n" }, { "category": "ECG", "chartdate": "2179-07-24 00:00:00.000", "description": "Report", "row_id": 146136, "text": "A-V sequential pacing\n\n" }, { "category": "ECG", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 146137, "text": "Baseline artifacts. Regular A-V sequential paced rhythm. There is one fusion\nbeat. Compared to the previous tracing of , except for one fusion beat,\nthere is no significant diagnostic change.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1286529, "text": "cv: vss av paced 75. sbp 87-98/ natrecor continues at .015 mics/kg/min\nswanz ganz numbers see careview.\n\nuo: foley draining clear yellow urine ~ 35 -40 cc/hr\n\ngi: incont of sm amt loose stool.\n\nneuro: slightly confused at times alt with orienated. at ~ 220 pt looking arounr room.\" I got to get a ricde out of here soon. confuseed/ haldol 2 mg po times one with good effect. Calm and cooperative.\n\nsleeping comfortably at present.\n'\nresp: breath sounds crackles at bilat bases, clear upper. O2 sats 4 l nc, sats 91-94 %\n" }, { "category": "Nursing/other", "chartdate": "2179-07-24 00:00:00.000", "description": "Report", "row_id": 1286522, "text": "CCU Nursing Progress Note\nS-\"I feel alittle better today\"\nO-Neuro-alert when awake, taking freq naps. Easily awakens. No signs of disorientation during the day. Appropiatly asking questions.\nCV-VSS natrecor increased .015mcg/kg/min and lasix gtt increased to 10mg/hr after 40mg IVB with good response. SBP 88-110 and dopamine decreased to 3mcg/kg/min (5.3) Hemodynamics improved with PAD 19-23 (29-30) last CO/CI/SVR 5.3/2.75/604 at 1700. MVO2 66.\nHR 70-80 AV paced, \"audible alarm\" around 1000. Pacer/AICD interagated by cardiology/battery OK. Wife states pt was at pacer clinic on and was told if they start to hear alarm/tone from pacer box around 10am it means his battery is getting low.\nResp-LS rales 1/2 up bilaterally, O2 5l np with O2 sats 91-94%. Easily SOB with activity.\nID afebrile\nGU-foley draining well on lasix gtt, Goal 1.5liters negative by am.\nGI-appetite good, needs some assist with setting up. 1 moderate BM soft OB negative.\nActivity-OOB chair for 4 hours tolerated well. Walking with 2 assist with gait steady but needs to hold on to something.\nSocial-daughters in and asking alot of questions. Wife in and spoke with cards fellow about POC.\nA/P ICM with end stage CHF on natrecor/lasix gtts to improve symptoms.\nMaintain SBP >85 and PAD >18<30, Goal I/O 1.5 liters negative\nFollow hemodynamics CO/CI/SVR q4-6hrs.\nMonitor electrolytes also.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-25 00:00:00.000", "description": "Report", "row_id": 1286523, "text": "NPN\nCCU\n7 PM- 7 AM\nCARDIOMYOPATHY\nS NO COMPLAINTS\nO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HR 70'S AVP..SBP BY NBP 90-100'S/50'S ON 3 MCG OF DOPA ...NATRECOR AT .015 AND LASIX 10 MG/HR ..PAD 22-24..CVP 14-16..C.O/INDEX 6.1/3.2..SVR 550 DENIES CP OR SOB..RR 28-32 UNLABORED ..ABLE TO SPEAK IN SHORT SENTENCES ..ALTHOUGH CXS REMAIN 2/3 UP BILAT ..PT ABLE TO SLEEP ON RIGHT SIDE ..LYING FLAT ..02 ON 4L NP ..WITH 02 SATS 92-94%..MV SAT 70\nGI/GU URINE OUTPUT BRISK ..200-350 CC Q2 ..K 3.3 REPLEATED WITH 40 MEQ KCL...CREAT 1.4\nA HEMODYN STABLE DIURESISING TO CURRENT MEDICAL MANAGEMENT\nP AM CXR ..FOLLOW PA #'S..GOAL 1500 CC AT MN\n" }, { "category": "Nursing/other", "chartdate": "2179-07-25 00:00:00.000", "description": "Report", "row_id": 1286524, "text": "CCU Nursing Progress Note\nS-\"I feel pretty good\"\nO-Neuro alert and oriented x3. More awake today, watching TV.\nCV-VSS Improved hemodynamics on Natrecor .015mcg/kg/min, lasix 10mg/hr and renal dose dopamine 3mcg/kg/min. PAD 19-13 and CO/CI/SVR 6.6/3.42/873.\nResp-LS rales 1/3 up bilaterally, O2 sats unchanged 93-95%.\nID afebrile\nGU-foley draining 100cc/hr.\nGI-appetite good, LBM \nActivity-OOB chair 4 hours. Improved gait, requring minimal assistance.\nSocial-family in to visit, spoke with MD.\nA/P-IMproved status on current regieme.\n Possibly start po meds. ?coreg\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-26 00:00:00.000", "description": "Report", "row_id": 1286525, "text": "NPN\nCCU\n7 PM - 7 AM\nCARDIOMYOPATHY\nS \" NO COMPLAINTS \"\nO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HR 70'S..FREQUENT EPISODES OF FAILURE TO SENSE ..WITH SPIKE LANDING AFTER THE QRS COMPLEX..NATRECOR AT .015 MCGS..DOPA AT 3 MCGS\nDENIES CP ..PAD 22-24..CVP 14-16..C.O 6.2/INDEX 3.2..SVR 580\nRESP ABLE TO SPEAK IN SHORT SENTENCES ..LUNGS UNCHANGES ..CXS 1/2 UP BILAT..ON 5L NP..ABLE TO LIE FLAT TO SLEEP\nGI DENIES NAUSEA ..APPETITE GOOD..\nGU BRISK DIURESIS ..MAINTAINED ON LASIX INFUSION AT 10 MG/HR ..U/O 200-400Q1/HR\nA DIURESIS TO PRESENT MEDICAL MANAGEMENT\nP AM CXR\nICD/DDD WITH INCREASED ECTOPY\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 1286527, "text": "NEURO: ORIENTE TO PERSON & PLACE, BUT NOT TIME/DATE. ASKING FOR SUPPER THIS AM UPON AWAKENING. MAE. COOPERATIVE. FOLLOWS COMMANDS.\n\nRESP: O2->4L NP. BS CLEAR WITH BIBASILAR CRACKLES. O2 SAT 94-96%. RR 18-24.\n\nCARDIAC: HR 70'S AVP WITH OCC. PVC'S. BP 92-113/51-76.PAD 30->17, CVP\n18->13, CO 5.3/2.75/1011, MVO2 67->63% ON LASIX GTT 10MG/HR, NATRECOR\n0.015MCG/KG, & DOPA 3MCG/KG. HCT 36, MG 2.2, K 3.8->TREATED WITH KCL\n40MEQ PB X1. DENIES CP/SOB. +BPPP.\n\nGI: APPETITE GOOD. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 100-200CC/HR.\nBUN/CREAT 25/1.1.\n\nID: AFEBRILE.\n\nAM LABS PENDING.\n\nPLAN: WEAN OFF GTTS->SWITCH TO PO MEDS.\n D/C SWAN.\n ? HOME WITH SERVICES/HOSPICE.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-26 00:00:00.000", "description": "Report", "row_id": 1286526, "text": "CCU NPN 7A-7P\nCV: cont on IV dopa 3mcg/kg/min, Natrecor .015mcg/kg/min and Dopa at 3mcg/kg/min, UO ~100cc/hr, neg 1L so far today. Denies SOB, has bibasilar crackles. Sat 94% on 4L NC. Lower ext edema reduced from Friday. HR 70's A-V paced, have printed strips where pacing spikes appear after the QRS, discussed with team who are calling EP to evaluate. EP stated that pt pacing was appropriate, safety pacing mechanism in effect. K+ 3.5, given 60 mEq KCL po. 3GMs Mag IV. OOB to chair for couple hours.\n\nGU: Cr improving, diuresing well to above regime, plan to cont for toady and convert to po meds tomorrow.\n\nNeuro: alert, sleeping often, oriented, no confusion. Wife felt MS improved from yesterday, spirits a bit better.\n\nSkin: intact.\n\nGI: given colace and senekot this AM, had sm formed BM, OB(-).\nAppetite fairly good.\n\nSoc: daughters in AM, wife and 8 yr old son in this afternoon, all updated by MD/RN. Wife verbalizing that they are prepared as a family to deal with the end, brought up hospice care, stating that for her and her son it would be better for him to be in a hospice center rather than at home when the time comes. I suggested the possibility of him being home on IV therapy if needed, she did not think he would like that option. Told her we would be trying to get him on to po meds and see how he does over next several days, that hope was to get him home. Pt has expressed desire to go home.\n\nA/P: pt tolerating current regime at present, diuresing well. Will cont IV gtts and try converting to po meds tomorrow. PT to eval once swan out, cont OOB to chair. Follow and repleat lytes as needed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 1286520, "text": "CCU NPN 7-11pm\nPt transferred from 3 for swan placement and management of CHF. See FHA.\n\nCV: swan placed, PAP 60's/24, CVP 22, PCWP 38, CO 5.4, CI 2.8, SVR 800 on 4.6mcg/kg/min and .01mcg/kg/min., Denies CP or SOB. To start lasix gtt and if tolerated will increase Natracor. HR 74 V-paced, BP 90-110/60. Edema of legs.\n\nResp: bibasilar crackles, sats 93% on 4L NC. No distress.\n\nNeuro: thought he saw a cat our in the , knows he is in the hospital and that it is .\n\nGI: refused dinner, has no appetite. No stool, refused colace.\n\nID: afebrile.\n\nSkin: intact.\n\nSoc: MD's spoke with wife on phone after swan placed.\n\nA/P: 75 yr old pt of Dr. transferred to CCU for management of heart failure, CI better than anticipated, will try lasix gtt rather than starting Milrinone. Cont to follow HD perameters, start Lasix at 5mg/hr.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-24 00:00:00.000", "description": "Report", "row_id": 1286521, "text": "Pt was transferd to CCU for SWAN line and Dopamine, and Natrecor gtts.\n\nNeuro: PT alert and oriented X3. Follows commands and moves all extremities in bed. Pt found 2 times trying to get OOB. When explained what time it was and the need for him to not get OOB due to lines and risk for falling he allowed us to assist him back to bed. He was alert to person, place, year and month, just not to time of day. PERRL. Speach clear. Pt did not sleep very much last night and was focused on eating breakfast so arround 4am he ate toast and had his decaf coffee.\n\nCV: Continues to be V-paced. BP stable on Dopamine titrated slightly during the night for low BP. Positive palpable pulses in all extremites. Denies chest pain or pressure all night. Right IJ swan line in place and FICK CO obtained. PT's EF prior to admission was low, roughly 15-20%.\n\nResp: Lungs clear with crackles in the bases. O2 sat 90-95% on 4l NC. Pt denies trouble breathing. RR non labored and . Pt continues on Natrecor 0.01mcg/kg/min and Lasix 5mg/hr gtts for diuresis and treatment of CHF. PT found to pull of oxygen from time to time. Oxygen reapplied and the importance of the oxygen and leaving it on were reinforced.\n\nGI: Tolerating diet. No nausea or vominting on shift. PT ate toast and drank fluid without difficulty. ALthough pt vomited potassium on shift.\n\nGU: Foley in place and draining clear yellow urine. Conitnues on Lasix and Natrecor gtts for diuresis.\n\nA/P: Continue diuresis with lasix and natrecor may need to add additonal agents or titrate due to pt's output averaging 60cc/hr. Fliud restrictions. Mointor neuro status closely and may need nursing station bed when he transfers to a floor bed. Monitor oxygen administration and respiratory status for s/s of worsening CHF. Continue with monitoring of PAP and obtain CO when ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 1286528, "text": "CCU NURSING PROGRESS NOTE 0700-1900\nCARDIAC--DOPAMINE WEANED OFF. LASIX GTT OFF. V-PACED. BP 88-110/60'S. RECEIVED CAPTOPRIL WITHOUT INCIDENCE. CO 4.6 WITH CI 2.3. PLS SEE FLOW SHEET FOR OBJECTIVE DATA. REMAINS ON NATRECOR GTT. SYTES REPLETED AS ORDERED.\n\nNEURO--BECOMING INCREASINGLY CONFUSED TO PLACE AND TIME. THINKS HE IS IN , IS PRESIDENT AND DOESN'T KNOW WHY HE IS HERE. REDIRECTED AND REORIENTED. MAE SPONT AND TO COMMAND. FOLLOWS COMMANDS CONSISTENTLY. PT IS HOH AND OFTEN ASKS TO HAVE QUESTIONS REPEATED.\n\nRESP--O2 AT 4L NC. BILATERAL BREATH SOUNDS ARE CLEAR, SOMEWHAT DIMINISHED IN BASES R>L. NO COUGH. SAO2 96-98%.\n\nGI--APPETITE GOOD FOR BREAKFAST AND LUNCH. STOOLING X4 SOFT FORMED STOOL.\n\nGU--LASIX GTT OFF. UO >60 CC HR. GOAL IS TO BE -500CC /24 HRS. PT IS >2.4L. WT IS DOWN 2.5KGS.\n\nENDO--FS 170. PT IS NOT ON FS AND IS NOT ON SSRI.\n\nSKIN--BUTTOCKS PINK OTHERWISE INTACT. SEVERAL AREAS OF ECCYMOISIS ON UE AND ABD (FROM HEPARIN SQ). OOB IN CHAIR X2 FOR >3HRS EACH TIME.\n\nPAIN--DENIES PAIN, SOB.\n\nID--AFEBRILE. NOT ON ABX.\n\nCOPING--WIFE IN TO VISIT ASKING QUESTIONS RE: MEDICATION BY MOUTH. SHE HAS PHONED X2 AND HAS BEEN UPDATED EACH TIME . PT IS CONFUSED AND HOH OFTEN ASKING TO REPEAT QUESTIONS. HIS WIFE PHONED TO TELL RN THAT PT IS CONFUSED BUT HE HAS BEEN CONFUSED ALL DAY.\n\nA--INCREASE IN CONFUSION. TOLERATING BEING OFF LASIX AND DOPAMINE GTTS FOR NOW.\n\nP--CON'T TO REDIRECT AND REORIENT AS NEEDED. REPLETE LYTES AS NEEDED.OFFER SUPPORT. PROVIDE SAFETY.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2172-07-30 00:00:00.000", "description": "Report", "row_id": 1661453, "text": "Respiratory Care Note\nPt received on PSV 10/5 - pt tolerating well - ABG is within normal limits with good oxygenation. BS coarse bilaterally - pt suctioned for moderate amts thick, yellow secretions. RSBI was 65 with a VT of 384 and RR 25. Pt placed on SBT 5/0 and weaned from sedation. Pt extubated to cool aerosol and NC without incident. Pt c/o SOB and was given Albuterol via neb. BS essentially clear, but slightly decreased with increased aeration after neb.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-30 00:00:00.000", "description": "Report", "row_id": 1661454, "text": "Nursing Progress Note\n0700-1900\nRight Lower Lobe Pneumonia\nReceived patient orally intubated and sedated on versed/fentanyl/propofol. Maintained on ..with a RR inthe 20's..tv of 450..f102 40%.. Decision made by MICU team to decreased sedation by half ..and was given 10 mg of iv valium to decrease patient's anxiety when shovel mask applied after extubation ( patient claustrophobic ) Sedation off at 1045..Extubated at 11:30. to shovel mask>prongs\nLungs decreased on the right. Strong cough clearing secretions in to tissue. Resp rate 22-28.. unlabored.\nCV HR 70-80's sinus ..SBP by aline 130-150's/60's..\nGI/GU Tolerating ice chips ...Diuresing on own\nComfort Given iubprofen times one for c/o headache. Patient with aches all over...Needing assist to roll.\nAccess Right IJ triple lumen\nID triple antibiotics ..Afebrile\nSuccessful Extubation\nAnticipate callout to floor in am\n" }, { "category": "Nursing/other", "chartdate": "2172-07-31 00:00:00.000", "description": "Report", "row_id": 1661455, "text": "Nursing Progress notes 0300\nReview carevue for all additional data\n\nEvents: No significant events overnight\n\nrt lower lobe pneumonia, extubated yesterday, close monitoring of O2 sats, resp care and continuing antibiotics.\n\nNeuro: Alert,oriented x3, following commands and MAE. C/o severe headache just prior to shift and patient feels better after dilaudid 2mg iv and more cooparative with care. Good effect with diluadid 2 mg for head ache.\n\nResp: Patient extubated yesterday and continued on O2 5L nasal canula and O2 sats 95-97%, and patient not very happy further weaning of O2 now. Bilateral lung sounds clear and diminished at the base more on rt base. Patient need more encouragement for deep breathing and cough exersises.\n\nCV: NSR, without any ectopy, SBP 100-130's monitoring via a line. afebrile and continued on antibiotics.\n\nGI: NPO, tolerating ice chips, abd soft, BS present and no BM this shift. UO 100-150 and 24hrs balance neg 500ml.\n\nSkin: Small abrasion over coccyx and open to air, no other skin issues\nAccess: PIVx1, RIJ Multi lumen and Lt radial A line.\n\nSocial: Family was at the bed side.\n\nPlan: Pain management\n monitor resp status wean further O2, if tolerated\n ? call out to floor.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-07-31 00:00:00.000", "description": "Report", "row_id": 1661456, "text": "7a-3p Nursing Progress Note\n\nNeuro: A/O x3, MAE equally; dilaudid prn back/shoulder pain. All procedures/POC explained to pt prior to initiation with verbalization of understanding.\nResp: Pt on 4L NC-sats WNL; lungs coarse/diminished on R/clear on L side; encouraging pt to CDB, has refused IS so far today. RR WNL with nonlabored respirations.\nCV: NSR no ectopy noted; BP stable. L rad Aline D/c'd; pulses present bilat. Trace edema noted. R IJ TLC intact with all ports patent; IVF at KVO. 2nd set cardiac enzymes pending from am episode of CP; no episodes this shift. Afebrile.\nGI/GU: Foley with good amts cl yellow urine noted. Abd soft/+BS; pt starting to take cl liquids without difficulty; will advance diet as tolerated.\nSkin: Open blister to coccyx; no other breakdown noted.\nSocial: wife/daughter present at bedside today; spoke to MICU team regarding pt condition/POC.\nPlan: Pt is c/o to floor; will cont to monitor and implement POC.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-29 00:00:00.000", "description": "Report", "row_id": 1661450, "text": "npn\nevents: pt bronched at bedside , bal taken from rightside for cx, no lesions or irritations noted, moderate secretions.\n\nneuro: pt still is awakening at times and thrashing about but not asevere as yesterday. sedated on propofl 65 mcg and versed 4mg . has received multiple boluses especially during bronch. pt started on fent at 25 mcg at 1830 due to continued inc. rr on cpap ventilation\n\npain: when alert pt denies pain with nodding but seems uncomfortable when not adequately sedated with continue pulling of restarints and attempts to sit up in bed. started on fent at 1830\n\ncad vss 70-84 sr no ectopy noted, abp 109/78 to 144/75, cvp 7. no issues\n\nresp: current vent settings cpap at 40% with rr teens to 20's with brief epsiodes into the 40 range. sats 97% pt started on fent for\n ? pain.\n\ngi: abd soft bs+, no bm this shift. + flatus, tf held for bronch and then restarted at 1500 at 20cc/hr goal is 90cc/hr.\n\ngu: uo 50-180cc/hr, pt is 564 negative at 1800.\n\nid: seen by id team. startedon clindamycin and flagyl and azithro dc'd.\nendo: no ssi needed all bs <150\nsocial: family at bedside all day.\n\nplan: cont to titrate sedation to keep pt comfortable, monitor temp , vs. cont with antb. therapy provide emotional support\n" }, { "category": "Nursing/other", "chartdate": "2172-07-30 00:00:00.000", "description": "Report", "row_id": 1661451, "text": "Resp: pt on psv 12/5/40%. Ett 7.5, 23 @ lip. BS are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. MDI's administered as ordered of alb with no adverse reactions. Vent changes to decrease ps to 10. Vt'd 400's, Ve's 10. No abg's this shift with RSBI=116. BAL negative. Will continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-30 00:00:00.000", "description": "Report", "row_id": 1661452, "text": "Nsg Progress Note 1900-0700\n\nCV - Pt febrile most of the night but at 0420 temp normal at 98.4 PO. HR stable 70-80's with no ectopy. BP stable with no fluctuations while sedated but when pt lightens - BP does elevate to 160/84. IVF at KVO due to large amt of fluid being received from other IV meds.\n\nResp - BS with crackles to the right and clear to the left. Presently on CPAP 40%. Suctioned q2 hours for scant to large amt secretions. Secretions are very thick and tan colored.\n\nGI - Tolerating TF's - able to increase rate to 40cc/hr with goal of 90cc. Abd soft with positive BS but no stool.\n\nGU - Foley cath draining adequate to large amt cl yellow urine.\n\nEndocrine - no insulin coverage required.\n\nNeuro - Continues to remain sedated on fent, midaz and propofol. Sedation level very consistent. Minimal spont movement of extremities - opens eyes to pain and some sounds. Does not respond to questions or commands. Nicotine patch placed on pat. Hand mitts placed on pat to prevent him from being able to extubate himself again. This appeared to have been successful over the course of the night.\n\nSkin - Coccyx area still red but no oozing or blistering. Kept open to air and pt turned side to side.\n\nDoppler to legs negative.\n\nSocial - Family left shortly after 8pm. Daughter called for an update and no further contact.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-07-27 00:00:00.000", "description": "Report", "row_id": 1661443, "text": "condition update\n1900 Pao2 was 58, pt placed on shovel mask. Pt then complained of feeling closotrophobic/anxious with mask, requesting n.c.. Abg repeated after 1/2 hr on 6 liters n.c. and pao2 was 61. (goal >60). Pt reported feeling more comfortable with n.c. - micu team is aware. Please see carevue for other specifics. Pt transferred to micu 6 at 2100 without incident.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-27 00:00:00.000", "description": "Report", "row_id": 1661444, "text": "Micu Nursing Progress Notes\nEvents: Pt transfered to MICU from SICU (pt's MIUC border), O2 sats borderline most of the night, Pt was on , pt's request, and O2 sats improved.\n\nResp: Pt arrived from SICU on 6l NC with O2 sats 91%, a face tent was placed on his chest to improve sats, but it had no effect due to his not letting the mask stay on his face. The flow meter was changed to a high flow to increase the amount of O2 reaching him. His O2 sats increased to 90-91% for a short time. He requested sleeping in the prone position so he was changed and his sats improved to 93-94%. He was given ativan for anxiety and fentanly for the pain in his shoulders (arthritis) and he fell asleep. At one point when the shovel mask was over his mouth and nose his O2 sats improved to 96-97% but he was very restless changing position frequently so the mask did not stay in place long. He stayed prone until 5am, when he switched back his sats dropped. They improved with coughing but it was difficult to get him to effectively cough. He refused to wear the mask higher. He is oriented and denies SOB.\n\nCardiac: B/p 97-110/50's, HR 104-115, SR-ST.\n\nGI: Abd soft and non tender, (+) bowel sounds. He is on a house diet and should be encouraged to drink to hydrate his secretions.\n\nGU: foley draining clear yellow secretions. U/O very good.\n\nID: He is afebrile, WBC's 12.2. He is receiving azrithomycin, vanco and levofloxacin.\n\nNeuro: He is oriented and cooperative but his is very definate as to what he will tolerate. He complains of anxiety/claustrophobia wit masks, so last night he was given ativan x3 (total of 2mg). He also c/o bilateral shoulder pain from arthritis so he was given total of 50 mcg of fentanyl.\n\nLines: pt came from sicu with a right radial A-line, a right groin triple lumen and a right AC peripheral. The Aline stopped working during the night and there was no blood return so it was D/C'ed, and the triple lumen was partially pulled out and there was no blood return from any ports so it was also D/C'ed.\n\nSocial: His wife and his son were in last night when he was transfered. His daughter in a new surgical intern at , she called 3 times for updates.\n\nPlan: encourage him to C&DB, try to mobilize him to help him bring up his secretions, support the family.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-27 00:00:00.000", "description": "Report", "row_id": 1661445, "text": "Respiratory Therapy\n\nPt was electively intubated for increasing hypoxemia this AM w/out incident by anesthesia. ETT #7.5 was advanced from 23 to to 25cm@lip per CXR. A few hours later pt self-extubated and was successfully re-intubated by anesthesia, same ETT size and placement. SpO2 slow to come up, FiO2 remains at 100%, PEEP ^12, CXR this AM was worsening from yesterday. ABG pending, awaiting new A-Line placment. Sputum culture/gram stain spec sent via ETT suctioning, mini-BAL w/ combicath kit also sent to lab for culture. All results pending. SpO2 now 97%, suctioning for small to large amounts of thick tannish/bloodtinged sputum, pt has very strong cough when suctioned. Continues on A/C ventilation w/ PIP/Pplat = 26/20, overbreathing set vent RR of 16 to rate mid 20s, maintaining Ve in low teens. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; check ABG when line placed; monitor oxygenation...\n" }, { "category": "Nursing/other", "chartdate": "2172-07-27 00:00:00.000", "description": "Report", "row_id": 1661446, "text": "Nursing Progress Note:\n\nPlease see chart for admission data.\n\nPt. intubated, self-extubated, and re-intubated. Pt. now sedated and has central and arterial lines.\n\nNeuro: Pt was alert and oriented this morning however he was very fatigued. His work of breathing increased as the morning progressed and by 0930 he was unable to perform any movement without increased fatigue. He was given 2 mg. Ativan for anxiety before being placed on NRB mask.Pt. was given boluses of Fentanyl and Versed post-intubation but this did not sedate him sufficently to tolerate ETT so pt. placed on gtts.Pt. is now sedated on 100mcg/hour and Versed 2mg/hour.\n\nResp: Pt. received on high flow face tent with NC as well and appeared comfortable. His RR and 02 sats started dropping to 88 soon after coming on shift and pt's work of breathing increased . He was placed on NRB mask which hi 02 sats up to 90% but he started using accessory muscles to breathe and became anxious and fatigued. An ABG was drawn which was 7.49/34/52, so the decsion was made to intubate pt. Anesthesia performed the intubation and pt. was started on Fentanyl and Versed gtts. Three hours later pt. was being assessed\nfor arterial line placement and he started coughing, woke up and started thrashing, and vomited the ETT out. Suction was performed immediately and pt. was sedated and re-intubated by anesthesia. Vent setting initially AC 600X16/100%/12. An ABG was acquired after intubation which was 7.44/39/251 so vent settings were changed to 500X18/60%/12. Lungs were initially very diminished on R with course L lobes but now are course with some wheezing on R with much improved air movement. L side is relatively clear. Pt. suctioned for minimal amounts of blood-tinged secretions. Bedside \"mini BAL\" performed by respiratory and sputum cx sent.\n\nCV: HR initially ST in 110s in the morning but now NSR in 90s with no ectopy. NBP 88-130s/50s-70s. L radial arteral line placed, ABP 90s/50s. Pt. also had R IJ TLC placed, placement confirmed by X-ray.\nCVP to be transduced.\n\nGI: BSX4, no BM on shift. OGT placed and put on LIWS. Plan is to consider starting tube feeds tomorrow.\n\nGU: Pt. has been autodiuresing but was given 20mg IV Lasix at 1000 to help respiratory status (pt. was aggressively fluid challenged in ED). UO has been 100-200cc/hour.\n\nSkin: Pt. has a wound on his buttock with Duoderm dressing, not visualized on shift.\n\nSocial: Wife in with pt. today, daughter and husband (both MDs) flew up from to see pt.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-07-28 00:00:00.000", "description": "Report", "row_id": 1661447, "text": "pt on versed and fentanyl for sedation. pt is lightly sedated. become aggitated when care given; additional sedation given and verbal reassurence as well as continuallly reorienting. when lighted sedation for wake up. pt followed commands but not consistantly.MAE.\nLungs: RRL markedly decreased. upper clear to coarse bases decreased to coarse. rhonchi heared throughout at times. vents as indicated changes made based on ABGS. CPT q4.\nCV: HR NSR to ST. SBP 90-100's. RIJ 3 lumen. CVP 9-10, no vea noted. Palp DP/PT.\nGI: ABD soft . good BS.NG lws.\n GU: urine out put amber to yellow . 25-50 an hour.\nskin: stage 2 decub on coccyx . area red . douderm applied. turned frequently\nplan\ncontinue with antibiotic.\nmonitor I/O closely.\nvent changes as indicated. ABG as indicated.\ndouderm to coccyx. frequent turns\npulm toilet as tolerated.\nmonitor hemodynamics closely.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-28 00:00:00.000", "description": "Report", "row_id": 1661448, "text": "resp care\npt remained on a/c 500x18 60% 12 peep with peak pressures of 20. Pt consistently overbreathing to a rate of 26. BS coarse bil. suct for sml amts of thick blood tinged tan sput. Desats with any movement and slowly recovers.Faint wheezes heard occ-responds to prn mdi.RSBI held due to peep level.Will cont to follow and make adjustments as needed.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-29 00:00:00.000", "description": "Report", "row_id": 1661449, "text": "Respiratory Therapy\n\nPt remains orally intubated/mechanically supported; weaned to PSV this shift, tolerating well. Bronch at bedside for BAL, spec sent to lab. SpO2 90s, suctioned for moderate amounts of thick tan sputum, MDI given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support; continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-26 00:00:00.000", "description": "Report", "row_id": 1661441, "text": "condition update\nPlease see carevue for specifics.\nPt arrived with acls emts at from osh. Initially tachy 110's, hypotensive 79/42, received 3 liters ns, and levophed was started and titrated to keep map >65. Levophed currently off, map maintaining >65. Right radial a-line placed, 02 sat 88% upon arrival, pa02 64. Pt placed on face mask and then non-rebreather. 02 sat currently 96-98%, pao2 92. Pt c/o sharp pain right chest with inspiration allowing him to only take rapid shallow breath, fentynal given with good effect, also received 800mg CTA done which was negative for pe, showed rll pna. Vanco/azithro initiated, levaquin continues. . stim. test done. Currently:\nNeuro: Alert and oriented x's 3, mae on bed, appropriately. Currently denies pain.\nCV: Normal sinus 90's, no ectopy. Ca+/Mag repleted overnight. Map > 65, off levo. LR continues at 125cc/hr.\nResp: LS clear, diminished right base. Non-productive cough noted.\nGi: Abd. soft, nontender. NPO. No bm.\nGU: Foley draining adequate amts clear amber urine.\nEndo: BS wnl.\nSocial: Wife at bedside or waiting room throughout the night, frequently updated by this rn.\nplan: Continue to monitor abg's, resp. status, pain management as necessary, emotional support, abx.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-26 00:00:00.000", "description": "Report", "row_id": 1661442, "text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nNEURO: A/O x 3, normal motor and sensory bilaterally. Has HX chronic headaches, no c/o pain today.\n\nRESP: 100% NRBM titrated to 6L NC, pt refusing ventimask and reports he feels better on NC- SPO2 stable at 93-94%, though ABG showing decr in PaO2 to 64, MICU team aware. RR 28-34. Using IS hourly, C/DB. Encouraged lateral positioning frequently but pt unable to comply due to bilateral shoulder arthritis. Lung sounds are decreased right lobe, clear on left. No pleuritic pain today.\n\nHEMODYNAMICS: ST 95-108, no ectopy. SBP arterial 88-95/50s, MAP > 60. No pressors or fluid bolus needed today- maintenance LR dc'd on rounds in am after 1LNS bolus given as ordered by team. U.O. 50-100ml/hr, amber. Peripheral edema present. Fluid balance +2500ml today thus far, 9L pos overall. No sx bleeding, fibrinogen 714, INR 1.6. Vitamin K 10mg po given.\n\nID: Afebrile. urine legionella, BC pending. No sputum production, dry cough.\n\nGI: Tolerating soft diet, fair to poor appetite. Hypoalbuminemia present. Nausea in am, responded to Zofran IV. Abd soft, nontender.\n\nSKN INTEGRITY: Stage II wound left coccyx area, 1.5x2cm. Wound is residual from heat blister. Wound bed red, no drainage. Duoderm placed to protect from further breakdown and promote healing. Pt encouraged to position self laterally, prefers to remain supine most of the day.\n\nPLAN OF CARE: Monitor resp status closely, encourage IS, C/DB, postural drainage as tolerates. Incr activity as tolerated. Antibiotics. Monitor fluid balance, keep MAP>65, u.o. >30ml/hr. Encourage nutrition. Skin care. Emotional support and education to pt and family ongoing.\n\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2172-07-25 00:00:00.000", "description": "Report", "row_id": 297800, "text": "Sinus tachycardia. Non-specific T wave inversion in lead III. Compared to\ntracing of sinus tachycardia and T wave inversion are new.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2101-08-26 00:00:00.000", "description": "Report", "row_id": 87433, "text": "PATIENT/TEST INFORMATION:\nIndication: intraop management\nHeight: (in) 71\nWeight (lb): 78\nBSA (m2): 1.41 m2\nBP (mm Hg): 109/58\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 11:44\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\nbody of the LAA. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal LV cavity\nsize. Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated ascending aorta. Moderately dilated aortic arch.\nSimple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets\n(3). Mild AS (AoVA 1.2-1.9cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Tricuspid valve not well\nvisualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nResults were personally reviewed with the MD caring for the patient.\n\nConclusions:\nPREBYPASS:\n\n1. The left atrium is normal in size. No spontaneous echo contrast or thrombus\nis seen in the body of the left atrium or left atrial appendage.\n2. Left ventricular wall thicknesses and cavity size are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis low normal (LVEF 50-55%).\n3. Right ventricular chamber size and free wall motion are normal.\n4. The ascending aorta is moderately dilated. The aortic arch is moderately\ndilated. There are simple atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta.\n5. The aortic valve is bicuspid. The aortic valve leaflets (3) are mildly\nthickened. There is mild aortic valve stenosis (area 1.2-1.9cm2).\n6. Mild to moderate (+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is mild mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen.\n7. There is no pericardial effusion.\n8. Dr. was notified in person of the results on at 757\n\nPOSTBYPASS\n\n1. Patient is on phenylephrine infusion\n2. LV functions is good with EF 55% and no wall motion abnormalities\n3. Aortic valve function has not changed. Aortic insufficiency is slightly\nworse and is now moderate.\n4. Ascending aorta is difficult to visualize with the dacron graft, at the\narch level the contours are smooth.\n5. Mitral valve continues to show mild prolapse, mitral regurgition remains\nthe same.\n6. Dr. was notified of findings.\n\n\n" }, { "category": "Echo", "chartdate": "2101-08-25 00:00:00.000", "description": "Report", "row_id": 87434, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease. ?\nHeight: (in) 72\nWeight (lb): 178\nBSA (m2): 2.03 m2\nBP (mm Hg): 135/88\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 10:41\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. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\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. Markedly dilated ascending\naorta. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\ngradient c/w minimal AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrial pressure is indeterminate. 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 ascending aorta is markedly dilated The aortic valve leaflets\n(3) are mildly thickened. There is a minimally increased gradient consistent\nwith minimal aortic valve stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Normal regional and global biventricular systolic function.\nMarkedly dilated ascending aorta.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-08-25 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1038885, "text": ", TSURG FA6A 8:23 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: assess fro stenosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with cad\n REASON FOR THIS EXAMINATION:\n assess fro stenosis\n ______________________________________________________________________________\n PFI REPORT\n No stenosis in the internal carotid arteries bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038535, "text": " 10:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: admit w/positive ST-?h/o aortic aneurysm\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with\n REASON FOR THIS EXAMINATION:\n admit w/positive ST-?h/o aortic aneurysm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:56 PM\n Normal chest, stomach distended with gas.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:19 P.M. \n\n HISTORY: Possible aortic aneurysm.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Lateral aspect right lower chest is excluded from the examination. Other\n pleural surfaces and the imaged regions of the lungs are normal. Heart size\n is normal. Thoracic aortic contour is unremarkable. Stomach is moderately to\n severely distended with gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-08-25 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1038884, "text": " 8:23 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: assess fro stenosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with cad\n REASON FOR THIS EXAMINATION:\n assess fro stenosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:34 PM\n No stenosis in the internal carotid arteries bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID ULTRASOUND\n\n INDICATION: Coronary artery disease.\n\n FINDINGS: RIGHT SIDE: There is no significant plaque seen with peak systolic\n velocity in the common carotid artery 42 cm/sec, proximal ICA 50 cm/sec, mid\n ICA 52 cm/sec, distal ICA 66 cm/sec and external carotid artery 64 cm/sec.\n ICA/CCA ratio 1.5. The flow in the vertebral artery is in antegrade\n direction.\n\n LEFT SIDE: There are no significant atherosclerotic changes with peak\n systolic velocity in the common carotid artery 65 cm/sec, proximal ICA 57\n cm/sec, mid ICA 51 cm/sec, distal ICA 69 cm/sec and external carotid artery 85\n cm/sec. ICA/CCA ratio 1.0. The flow in the vertebral artery is in antegrade\n direction.\n\n IMPRESSION: No evidence of stenosis in the internal carotid arteries\n bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-08-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1039757, "text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?? ptx after CT removal\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with\n REASON FOR THIS EXAMINATION:\n ?? ptx after CT removal\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 11:20 AM\n Minimal left apical pneumothorax, followup on the subsequent radiograph is\n recommended. Worsening of bibasilar atelectasis are most likely due to\n termination of mechanical ventilation.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after chest tube removal.\n\n Portable AP chest radiograph was compared to .\n\n The patient is after median sternotomy and CABG. In the interim, the ET tube,\n the Swan-Ganz catheter, the mediastinal drains and the chest tubes have been\n removed. The cardiomediastinal silhouette is stable. The lung volumes are\n lower, which is most likely due to termination of mechanical ventilation with\n slight worsening of bibasilar atelectasis. No pleural effusion is\n demonstrated. A small left apical pneumothorax is present. No evidence of\n failure is seen.\n\n" }, { "category": "Radiology", "chartdate": "2101-08-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1039758, "text": ", TSURG FA6A 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?? ptx after CT removal\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with\n REASON FOR THIS EXAMINATION:\n ?? ptx after CT removal\n ______________________________________________________________________________\n PFI REPORT\n Minimal left apical pneumothorax, followup on the subsequent radiograph is\n recommended. Worsening of bibasilar atelectasis are most likely due to\n termination of mechanical ventilation.\n\n" }, { "category": "Radiology", "chartdate": "2101-08-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1039254, "text": ", TSURG CSRU 1:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal -will be\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p repl. asc. aorta/cabg x2\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal -will be in CVICU approx 1PM\n please call first\n ______________________________________________________________________________\n PFI REPORT\n Expected postoperative appearance.\n\n" }, { "category": "Radiology", "chartdate": "2101-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038536, "text": ", TSURG FA6A 10:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: admit w/positive ST-?h/o aortic aneurysm\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with\n REASON FOR THIS EXAMINATION:\n admit w/positive ST-?h/o aortic aneurysm\n ______________________________________________________________________________\n PFI REPORT\n Normal chest, stomach distended with gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-08-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1039253, "text": " 1:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal -will be\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p repl. asc. aorta/cabg x2\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal -will be in CVICU approx 1PM\n please call first\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 7:14 PM\n Expected postoperative appearance.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORT LINE\n\n REASON FOR EXAM: 82-year-old woman status post replacement of ascending\n aorta/CABG x2. Postop film.\n\n Since , there has been recent sternotomy for ascending aorta\n replacement and CABG.\n\n The overall appearance is expected. The ETT tip is 6 cm above the carina. The\n nasogastric tube ends in the stomach. The Swan-Ganz ends in the right\n pulmonary artery. Two mediastinal drains and one left chest tube are in\n place.\n\n There is new bilateral mid lung atelectasis, new small left pleural effusion\n and moderate retrocardiac atelectasis. There is no pneumothorax. Widening of\n the mediastinum is expected. There is a questionable mild volume overload.\n\n" }, { "category": "ECG", "chartdate": "2101-08-26 00:00:00.000", "description": "Report", "row_id": 221964, "text": "Sinus rhythm. Right bundle-branch block wih left axis deviation consistent\nwith left anterior fascicular block. Non-specific ST-T wave changes.\nQTc interval prolongation. Compared to the previous tracing of these\nabnormalities are new. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2101-08-24 00:00:00.000", "description": "Report", "row_id": 221965, "text": "Normal sinus rhythm. T wave inversions in leads III and aVF suggest possible\ninferior ischemia. Compared to the previous tracing of no diagnostic\ninterval change.\n\n" }, { "category": "ECG", "chartdate": "2101-08-23 00:00:00.000", "description": "Report", "row_id": 221966, "text": "Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\n\n" }, { "category": "Nursing", "chartdate": "2101-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639286, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Intubated & sedated on propofol. A-paced @ 84 to override VEA. Lytes\n repleted on prior shift & are WNL. Underlying rhythm=NSR @ 80.\n Continues to be hypovolemic with low filling pressures & MVO2.\n HCT=25.9 after 1UPRBC.Adeq hourly u/o. strong pedal pulses. On insulin\n gtt. back pain.\n Action:\n Transfused another UPRBC. Weaned sedation. Began vent wean.Hourly\n glucose levels. Morphine 4mg ivp prn.\n Response:\n Repeat HCT =30.9 Filling pressures and MV02 normalized. Met extubation\n requirements-> extubated without incidence to 70% OFM (+) 4lnc. Insulin\n gtt adusted per CVICU sliding scale. Back pain after morphine and\n repositioning.\n Plan:\n Continue to monitor hemodynamics. Instruct in use of I.S..transition\n insulin gtt to sc insulin.medicate to keep acceptable pain level.\n" }, { "category": "Nursing", "chartdate": "2101-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639378, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n s/p cabg, asc ao repair. Sternotomy. CT remain. Also c/o back pain.\n Action:\n Analgesia of percocet 10 ml prn (q4-5hr w/ effect). Reposition and oob\n to ch w/ relief of back discomfort.\n Response:\n States pain relief to 5 out of 10 but acceptable level\n Plan:\n Cont analgesia, reposition for comfort.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt s/p cabg x2. asc aorta graft repair. Hemodynamically stable pod\n 1.occas PVC noted. hct 31. cont dark thin serosang dng from CT. A + V\n wires present and function.\n Action:\n po lopressor began as well as iv lasix. CT remain. Hct check this\n afternoon, stable. Swan d/c w/out incident.\n Response:\n Stable day. Tol lopressor 25 mg po. Sbp 100-120mmhg most of shift.\n Plan:\n Goal sbp 100-120. cont beta blockade. Cont post-op regime.\n" }, { "category": "Physician ", "chartdate": "2101-08-28 00:00:00.000", "description": "Intensivist Note", "row_id": 639444, "text": "CVICU\n HPI:\n 24 Hour Events:\n CCO PAC - STOP 10:02 AM\n Post operative day:\n POD#2 - cabg,ascending aorta replacement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:09 PM\n Morphine Sulfate - 06:30 AM\n Other medications:\n Flowsheet Data as of 07:55 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: 36.8\nC (98.3\n HR: 79 (76 - 92) bpm\n BP: 105/58(69) {105/58(69) - 105/58(69)} mmHg\n RR: 16 (10 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 78.5 kg\n Height: 72 Inch\n CVP: 7 (6 - 14) mmHg\n PAP: (29 mmHg) / (14 mmHg)\n CO/CI (Fick): (5.7 L/min) / (2.8 L/min/m2)\n CO/CI (CCO): (5.1 L/min) / (2.1 L/min/m2)\n SvO2: 64%\n Total In:\n 1,593 mL\n 430 mL\n PO:\n 990 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 603 mL\n 70 mL\n Blood products:\n Total out:\n 3,440 mL\n 960 mL\n Urine:\n 2,150 mL\n 740 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,847 mL\n -530 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.42/41/71/27/1\n Labs / Radiology\n 165 K/uL\n 11.3 g/dL\n 133 mg/dL\n 1.3 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 102 mEq/L\n 133 mEq/L\n 31.4 %\n 13.2 K/uL\n [image002.jpg]\n 01:00 AM\n 02:00 AM\n 03:00 AM\n 04:02 AM\n 04:25 AM\n 06:00 AM\n 04:22 PM\n 04:33 PM\n 02:03 AM\n 02:08 AM\n WBC\n 10.3\n 13.2\n Hct\n 31.0\n 31.9\n 31.4\n Plt\n 163\n 165\n Creatinine\n 1.0\n 1.3\n TCO2\n 28\n 28\n Glucose\n 95\n 106\n 102\n 100\n 93\n 118\n 133\n Other labs: PT / PTT / INR:12.0/27.6/1.0, Fibrinogen:240 mg/dL, Lactic\n Acid:0.9 mmol/L, Ca:8.1 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:57 PM\n Trauma line - 01:58 PM\n 20 Gauge - 02:26 PM\n" }, { "category": "Physician ", "chartdate": "2101-08-28 00:00:00.000", "description": "Intensivist Note", "row_id": 639446, "text": "CVICU\n HPI:\n 82 y.o. male s/p CABG / Asc Ao Replacement\n 24 Hour Events:\n CCO PAC - STOP 10:02 AM\n Diuresis with lasix\n good response except increased creat\n Increased CT drainage\ns remain on suction\n Post operative day:\n POD#2 - cabg,ascending aorta replacement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:09 PM\n Morphine Sulfate - 06:30 AM\n Other medications:\n Flowsheet Data as of 07:55 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: 36.8\nC (98.3\n HR: 79 (76 - 92) bpm\n BP: 105/58(69) {105/58(69) - 105/58(69)} mmHg\n RR: 16 (10 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 78.5 kg\n Height: 72 Inch\n CVP: 7 (6 - 14) mmHg\n PAP: (29 mmHg) / (14 mmHg)\n CO/CI (Fick): (5.7 L/min) / (2.8 L/min/m2)\n CO/CI (CCO): (5.1 L/min) / (2.1 L/min/m2)\n SvO2: 64%\n Total In:\n 1,593 mL\n 430 mL\n PO:\n 990 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 603 mL\n 70 mL\n Blood products:\n Total out:\n 3,440 mL\n 960 mL\n Urine:\n 2,150 mL\n 740 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,847 mL\n -530 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.42/41/71/27/1\n Labs / Radiology\n 165 K/uL\n 11.3 g/dL\n 133 mg/dL\n 1.3 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 102 mEq/L\n 133 mEq/L\n 31.4 %\n 13.2 K/uL\n [image002.jpg]\n 01:00 AM\n 02:00 AM\n 03:00 AM\n 04:02 AM\n 04:25 AM\n 06:00 AM\n 04:22 PM\n 04:33 PM\n 02:03 AM\n 02:08 AM\n WBC\n 10.3\n 13.2\n Hct\n 31.0\n 31.9\n 31.4\n Plt\n 163\n 165\n Creatinine\n 1.0\n 1.3\n TCO2\n 28\n 28\n Glucose\n 95\n 106\n 102\n 100\n 93\n 118\n 133\n Other labs: PT / PTT / INR:12.0/27.6/1.0, Fibrinogen:240 mg/dL, Lactic\n Acid:0.9 mmol/L, Ca:8.1 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n OOB, IS and phys therapy\n Cont lopressor and keep SBP < 120mmHg\n Hold diuresis today given increased creat and follow I/O\ns and Creat\n Keep CT\ns for now given increased output.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:57 PM\n Trauma line - 01:58 PM\n 20 Gauge - 02:26 PM\n" }, { "category": "Nursing", "chartdate": "2101-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639503, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Aao.3. taking percocet elix prn for incisional and back pain w/ effect.\n NSR. Tol lopressor 25 mg po bid. A +V wires present and function.\n Capped at present. Diuresing w/ lasix. Pedal pulses palp except rt DP\n by dopppler. Lungs CTA. O2 3l n/c w/ o2 sats 91-96%. Using IS to\n 1200cc. good non-pro cough. Mediastinal and pleural tubes remain for\n mod amt serosang dng. No airleak noted. Appetite poor today. No nausea.\n Bsp. + frequent belching. Glucose @ 1630 145-> 4 unit reg insulin SQ.\n uop qs via foley. On hytrin. Skin intact except for inc. family in to\n visit aware of probable transfer. Amb x 2 today. Not yet seen by PT.\n Action:\n Cont to progress.\n Response:\n Stable day.\n Plan:\n Transfer to 6. PT to see.\n s/p cabg x c2. LIMA-LAD, SVG-RCA. Ascending Aortic aneurysm repair w/\n 30mm Gelweave graft . progressing well post-op.\n" }, { "category": "Nursing", "chartdate": "2101-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639214, "text": "Labile bp with low filling pressures,brisk huo,hct 20% & svo2 in the\n mid 50\ns on arrival. Volume given,ntg titrated to maintain sbp between\n 100 -120,prbc\ns x 2 infused with rising filling pressures,slowly\n improving svo2. repeat hct pending.mildly oozy from ct\ns treated with\n increased peep & protamine with resolution.daughter in,questions\n answered & icu visitor guidelines.\n" }, { "category": "Nursing", "chartdate": "2101-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639259, "text": "Continued to appear hypovolemic with svo2 < 60%,low filling\n pressures,labile bp. Additional volume given with improved\n hemodynamics,ci finally > 2,svo2 mid 60\ns,cvp 9-12,pad 18-24.plan to\n attempt weaning. pvc\ns with couplets & triplets continue,a paced for\n ectopy suppression,amiodarone given & lytes repleted with improvement\n ,see ..v wires not assessed as yet due to same.\n" }, { "category": "Physician ", "chartdate": "2101-08-27 00:00:00.000", "description": "ICU Note - CVI", "row_id": 639345, "text": "CVICU\n HPI:\n Chief complaint:\n HD5\n POD #1\n 82 yoM s/p CABG x2(Lima->Lad/SVG->RCA)/Asc. Ao.Replacement (#30mm\n Gelweave graft)-\n PMH:HTN, ^chol, COPD, R leg injury,\n :indapamide 1.25', hytrin 2', advair 250-50\", alprazolam 0.5',\n simvastatin 20', atenolol 25'\n PMHx:\n Current medications:\n 2. Acetaminophen 3. 4. Aspirin 5. Calcium Gluconate 6. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10.\n Fluticasone-Salmeterol (250/50)\n 11. Furosemide 12. Influenza Virus Vaccine 13. Insulin 14. Magnesium\n Sulfate 15. Metoprolol Tartrate\n 16. Metoclopramide 17. Morphine Sulfate 19. Oxycodone-Acetaminophen\n 21. Pneumococcal Vac Polyvalent 22. Potassium Chloride 23. Propofol 24.\n Ranitidine 25. Ranitidine\n 26. Simvastatin 27. Sodium Chloride 0.9% Flush 28. Terazosin 29.\n Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 01:37 PM\n INVASIVE VENTILATION - START 01:38 PM\n ARTERIAL LINE - START 01:57 PM\n CCO PAC - START 01:58 PM\n TRAUMA LINE - START 01:58 PM\n EKG - At 02:16 PM\n INVASIVE VENTILATION - STOP 12:25 AM\n EXTUBATION - At 12:28 AM\n Post operative day:\n POD#1 - cabg,ascending aorta replacement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:45 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 06:35 PM\n Ranitidine (Prophylaxis) - 07:14 PM\n Carafate (Sucralfate) - 11:00 PM\n Morphine Sulfate - 12:01 AM\n Other medications:\n Flowsheet Data as of 02:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 80 (77 - 100) bpm\n BP: 126/59(82) {79/37(49) - 134/66(87)} mmHg\n RR: 17 (12 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 78.5 kg\n Height: 72 Inch\n CVP: 7 (6 - 16) mmHg\n PAP: (29 mmHg) / (14 mmHg)\n CO/CI (Fick): (5 L/min) / (2.5 L/min/m2)\n CO/CI (CCO): (5.1 L/min) / (2 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% sat: 58 - 65\n Total In:\n 7,252 mL\n 683 mL\n PO:\n 480 mL\n Tube feeding:\n IV Fluid:\n 5,752 mL\n 203 mL\n Blood products:\n 1,500 mL\n Total out:\n 1,860 mL\n 1,680 mL\n Urine:\n 1,320 mL\n 710 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 5,392 mL\n -997 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 38\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.40/43/89.//0\n Ve: 8.7 L/min\n PaO2 / FiO2: 127\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 : good air entry), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\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 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 163 K/uL\n 11.3 g/dL\n 93\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 104 mEq/L\n 134 mEq/L\n 31.0 %\n 10.3 K/uL\n [image002.jpg]\n 10:00 PM\n 10:53 PM\n 11:04 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:00 AM\n 04:02 AM\n 04:25 AM\n 06:00 AM\n WBC\n 10.3\n Hct\n 30.4\n 31.0\n Plt\n 163\n Creatinine\n 1.0\n TCO2\n 26\n 28\n Glucose\n 95\n 83\n 103\n 95\n 106\n 102\n 100\n 93\n Other labs: PT / PTT / INR:12.7/29.0/1.1, Fibrinogen:240 mg/dL, Lactic\n Acid:0.9 mmol/L, Ca:7.5 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: D/C Swan.Start diuresis and Lopressor. Outof bed\n in chair.\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:57 PM\n Trauma line - 01:58 PM\n 20 Gauge - 02:26 PM\n 16 Gauge - 02:28 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:\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2101-08-27 00:00:00.000", "description": "Intensivist Note", "row_id": 639318, "text": "CVICU\n HPI:\n 82 y.o. male s/p CABG / Asc Ao Replacement\n 24 Hour Events:\n OR RECEIVED - At 01:37 PM\n INVASIVE VENTILATION - START 01:38 PM\n ARTERIAL LINE - START 01:57 PM\n TRAUMA LINE - START 01:58 PM\n CCO PAC - START 01:58 PM\n EKG - At 02:16 PM\n INVASIVE VENTILATION - STOP 12:25 AM\n EXTUBATION - At 12:28 AM\n Post operative day:\n POD#1 - cabg,ascending aorta replacement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:45 PM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Insulin - Regular - 06:35 PM\n Ranitidine (Prophylaxis) - 07:14 PM\n Carafate (Sucralfate) - 11:00 PM\n Morphine Sulfate - 12:01 AM\n Other medications:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 89 (77 - 100) bpm\n BP: 110/56(75) {79/37(49) - 139/66(92)} mmHg\n RR: 20 (10 - 20) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 78.5 kg\n Height: 72 Inch\n CVP: 16 (8 - 16) mmHg\n PAP: (41 mmHg) / (23 mmHg)\n CO/CI (Fick): (4.4 L/min) / (2.2 L/min/m2)\n CO/CI (CCO): (3.7 L/min) / (2.4 L/min/m2)\n SvO2: 55%\n Mixed Venous O2% sat: 58 - 65\n Total In:\n 7,252 mL\n 142 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,752 mL\n 142 mL\n Blood products:\n 1,500 mL\n Total out:\n 1,860 mL\n 960 mL\n Urine:\n 1,320 mL\n 310 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 5,392 mL\n -818 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.40/43/89/26/0\n PaO2 / FiO2: 127\n Labs / Radiology\n 163 K/uL\n 11.3 g/dL\n 93\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 104 mEq/L\n 134 mEq/L\n 31.0 %\n 10.3 K/uL\n [image002.jpg]\n 10:00 PM\n 10:53 PM\n 11:04 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:00 AM\n 04:02 AM\n 04:25 AM\n 06:00 AM\n WBC\n 10.3\n Hct\n 30.4\n 31.0\n Plt\n 163\n Creatinine\n 1.0\n TCO2\n 26\n 28\n Glucose\n 95\n 83\n 103\n 95\n 106\n 102\n 100\n 93\n Other labs: PT / PTT / INR:12.7/29.0/1.1, Fibrinogen:240 mg/dL, Lactic\n Acid:0.9 mmol/L, Ca:7.5 mg/dL, Mg:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n D/C PAC\n OOB today\n Start lasix for diuresis\n Would start low dose B-Blocker\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:57 PM\n Trauma line - 01:58 PM\n CCO PAC - 01:58 PM\n 20 Gauge - 02:26 PM\n 16 Gauge - 02:28 PM\n" }, { "category": "Nursing", "chartdate": "2101-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639253, "text": "Continued to appear hypovolemic with svo2 < 60%,low filling\n pressures,labile bp. Additional volume given with improved\n hemodynamics,ci finally > 2,svo2 mid 60\ns,cvp 9-12,pad 18-24. pvc\n continue,a paced for ectopy suppression & lytes repleted with\n improvement ,see .\n" }, { "category": "Nursing", "chartdate": "2101-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639254, "text": "Continued to appear hypovolemic with svo2 < 60%,low filling\n pressures,labile bp. Additional volume given with improved\n hemodynamics,ci finally > 2,svo2 mid 60\ns,cvp 9-12,pad 18-24. pvc\n continue,a paced for ectopy suppression & lytes repleted with\n improvement ,see ..v wires not assessed as yet due to same.\n" }, { "category": "Nursing", "chartdate": "2101-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639402, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o L back(chronic) and incisional pain, rating pain despite\n q3-4h roxicet, SBP staying ~ 130, shallow respirations, poor cough\n effort, unable to sleep.\n Action:\n Morphine 4mg IV x 2 and 2mg IV x 1 in addition to 10 ml po roxicet x\n 2.\n Response:\n Pt able to sleep, rates pain after IV morphine\n Plan:\n Medicate q3-4h with po pain med, ? change po med to dilaudid if pain\n not better controlled.\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR(77-94) with rare PVC, SBP 90\ns to 120 with pain control. Tolerating\n increase in metoprolol, no IV pressor use. Sats 94-95%, PO2 71. chest\n tubes to Sx, no air leak, no crepitus, small amts serosanguinous\n drainage. FSBS 166 at 2300. Foley to CD, creatinine up to 1.3. T max\n 100.1 po current 98.3, WBC up to 13K.\n Action:\n Pain control, SBP < 120, q2h C, DB and IS use, 50% Face Mask added.\n Response:\n Hemodynamically stable post cardiac surgery.\n Plan:\n Aggressive pulm hygiene,repeat WBC, Increase activity, advance diet.\n DC R radial aline and foley. New peripheral IV then DC RIJ trauma\n line. ? transfer to 6 later today.. FSBS AC and HS\n" }, { "category": "Physician ", "chartdate": "2101-08-28 00:00:00.000", "description": "ICU Note - CVI", "row_id": 639477, "text": "CVICU\n HPI:\n 82 yoM s/p CABG x2(Lima->Lad/SVG->RCA)/Asc. Ao.Replacement (#30mm\n Gelweave graft)-\n Chief complaint:\n PMHx:\n HTN, ^chol, COPD, R leg injury\n Current medications:\n :indapamide 1.25', hytrin 2', advair 250-50\", alprazolam 0.5',\n simvastatin 20', atenolol 25'\n 24 Hour Events:\n CCO PAC - STOP 10:02 AM\n Post operative day:\n POD#2 - cabg,ascending aorta replacement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:09 PM\n Morphine Sulfate - 06:30 AM\n Other medications:\n Flowsheet Data as of 02:31 PM\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: 35.6\nC (96.1\n HR: 81 (76 - 92) bpm\n BP: 118/59(78) {91/45(63) - 126/60(83)} mmHg\n RR: 19 (7 - 25) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 78.5 kg\n Height: 72 Inch\n Total In:\n 1,593 mL\n 910 mL\n PO:\n 990 mL\n 840 mL\n Tube feeding:\n IV Fluid:\n 603 mL\n 70 mL\n Blood products:\n Total out:\n 3,440 mL\n 1,760 mL\n Urine:\n 2,150 mL\n 1,400 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,847 mL\n -850 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: 7.42/41/71/27/1\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 : Clear), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 165 K/uL\n 11.3 g/dL\n 133 mg/dL\n 1.3 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 102 mEq/L\n 133 mEq/L\n 31.4 %\n 13.2 K/uL\n [image002.jpg]\n 01:00 AM\n 02:00 AM\n 03:00 AM\n 04:02 AM\n 04:25 AM\n 06:00 AM\n 04:22 PM\n 04:33 PM\n 02:03 AM\n 02:08 AM\n WBC\n 10.3\n 13.2\n Hct\n 31.0\n 31.9\n 31.4\n Plt\n 163\n 165\n Creatinine\n 1.0\n 1.3\n TCO2\n 28\n 28\n Glucose\n 95\n 106\n 102\n 100\n 93\n 118\n 133\n Other labs: PT / PTT / INR:12.0/27.6/1.0, Fibrinogen:240 mg/dL, Lactic\n Acid:0.9 mmol/L, Ca:8.1 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal:\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:57 PM\n 20 Gauge - 02:26 PM\n Prophylaxis:\n DVT: Boots\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": "2101-08-28 00:00:00.000", "description": "ICU Note - CVI", "row_id": 639478, "text": "CVICU\n HPI:\n 82 yoM s/p CABG x2(Lima->Lad/SVG->RCA)/Asc. Ao.Replacement (#30mm\n Gelweave graft)-\n Chief complaint:\n PMHx:\n HTN, ^chol, COPD, R leg injury\n Current medications:\n :indapamide 1.25', hytrin 2', advair 250-50\", alprazolam 0.5',\n simvastatin 20', atenolol 25'\n 24 Hour Events:\n CCO PAC - STOP 10:02 AM\n Post operative day:\n POD#2 - cabg,ascending aorta replacement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:09 PM\n Morphine Sulfate - 06:30 AM\n Other medications:\n Flowsheet Data as of 02:31 PM\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: 35.6\nC (96.1\n HR: 81 (76 - 92) bpm\n BP: 118/59(78) {91/45(63) - 126/60(83)} mmHg\n RR: 19 (7 - 25) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 78.5 kg\n Height: 72 Inch\n Total In:\n 1,593 mL\n 910 mL\n PO:\n 990 mL\n 840 mL\n Tube feeding:\n IV Fluid:\n 603 mL\n 70 mL\n Blood products:\n Total out:\n 3,440 mL\n 1,760 mL\n Urine:\n 2,150 mL\n 1,400 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,847 mL\n -850 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: 7.42/41/71/27/1\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 : Clear), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 165 K/uL\n 11.3 g/dL\n 133 mg/dL\n 1.3 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 102 mEq/L\n 133 mEq/L\n 31.4 %\n 13.2 K/uL\n [image002.jpg]\n 01:00 AM\n 02:00 AM\n 03:00 AM\n 04:02 AM\n 04:25 AM\n 06:00 AM\n 04:22 PM\n 04:33 PM\n 02:03 AM\n 02:08 AM\n WBC\n 10.3\n 13.2\n Hct\n 31.0\n 31.9\n 31.4\n Plt\n 163\n 165\n Creatinine\n 1.0\n 1.3\n TCO2\n 28\n 28\n Glucose\n 95\n 106\n 102\n 100\n 93\n 118\n 133\n Other labs: PT / PTT / INR:12.0/27.6/1.0, Fibrinogen:240 mg/dL, Lactic\n Acid:0.9 mmol/L, Ca:8.1 mg/dL, Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Assessment and Plan:\n OOB, IS and phys therapy\n Cont lopressor and keep SBP < 120mmHg\n Hold diuresis today given increased creat and follow I/O\ns and Creat\n Keep CT\ns for now given increased output.\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal:\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:57 PM\n 20 Gauge - 02:26 PM\n Prophylaxis:\n DVT: Boots\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/other", "chartdate": "2186-02-05 00:00:00.000", "description": "Report", "row_id": 1555334, "text": "NPN :\nPlease see transfer note and careview for details.\n\nPt is called out, waiting for a bed on the floor, alert, oriented to name and place only, PICC line inserted, on Vancomycin and Zosyn, TF 50 cc/hr well tolerated, Foley adequate U/O, used incentive spirometer, V/S stable.\n" }, { "category": "Nursing/other", "chartdate": "2186-02-06 00:00:00.000", "description": "Report", "row_id": 1555335, "text": "NPN 1900-0700\nNeuro; Pt. alert and intermitenly disoriented. Talking to self and easy redirected. MAE. Speech garbeled but able to understand for the most part.\n\nResp: LS clear and dim at bases. On O2 at 2L/min with adequate O2 sat. Congested non productive cough since adm. CXR ordered for AM.\n\nCV: VSS. BP 100's-130's/60's, HR 90's-100's A-fib with occ. PVCs. No edema. New L PICC inserted on at bdside and workning well. Started on Coumadin last evening.\n\nGI; NPO. On TF via PEG. Probalance at goal and tolerating wellwith no residuals. No BM at this time. BS+.\n\nGU: Foley cath in place and draining adequate amounts of clear yellow urine.\n\nID: Afebrile this shift. Started on Vanco and Zosyn today. Cx. data pending.\n\nSkin: Abrasion to R arm from old Midline site,? tape burn. Area scabing over. Dsg. to decrease friction. Abrasion to L ankle and R knee allscabed over and open to air.\n\nSocial; Pt. is a full code. No visitors this shift.\n\nPlan; Pt. called out to medical unit and waiting for a bed. Transfer note initiated. F/U cxr for possoble developing pna.\n" }, { "category": "Nursing/other", "chartdate": "2186-02-04 00:00:00.000", "description": "Report", "row_id": 1555330, "text": "Admit Note:\nHx: 79yr male presented to EW from rehab s/p R MCA stroke. Per report pt began w/ fever several days ago w/ ? infected R midline. Midline was D/C's. On pt w/ decreasing MS. In EW pt initially afebrile, bld cx and UA cx sent. pt to CT which showed no acute hemorrhage. Upon return from CT pt noted to be in afib w/ RVR and pt noted to be febrile to 101.8. Pt received total lopressor 20mg IV as well as 25mg via NG tube, tylenol 1gm, Anceph, vanc, ceftriaxone, and acyclovir. HR responded moderately well to lopressor down to low 100's from 120's. BP tolerated well though SBP down to 90's X1 tx w/ 500ml FB. Pt was transferred to for futher monitoring and care.\n\nPlease see careview for all objective data:\n\nROS:\n\nNeuro: Pt w/ alert at times though falls asleep mid sentence at times. oriented X , vague and confused at times though pleasant and cooperative. Follows commands, MAE. R pupil noted to be irregular otherwise pupils equal and briskly reactive to light. Pt denies HA, numbness, tingling or visual changes.\n\nResp: BBS CTA to diminshed at bases. Pox remains 96-100% on 4L NC. ABG 7.50/34/91 Serum CO2 33 in EW. Pt w/ occasional loose NP.\n\nCV: Hr initially 120's w/ brief episodes to 150's. Pt given 250ml NS bolus, lopressor 5mg IV X 2 w/ moderate effect. Pt was then given Lopressor 25mg via NG tube. Hr now 90's to 110, remains afib w/ occasional PVC. BP remains stable. CK has been 65 and 61 w/ troponin <0.01 X2 sets. 3rd set cardiac enzymes due at 0445. Pt remains free of s/s CP, SOB diaphoresis or distress.\n\nFEN: Pt remains NPO. Cardiac enzymes as above. Pt not voiding. Was straight cathed in EW this afternoon per report. Pt attempted to use urinal multiple X's though unable to void. Foley catheter was placed w/o incident and now draining clear yellow urine QS. Pt has also attempted to use bedpan several X's though no BM this shift. Abd soft, non-tender. BS present X4.\n\nSocial: Call from Son who is MD , updated on pt status and POC.\n\nPlan: Continue to monitor VS and hemodynamic status. Follow labs and cardiac enzymes as ordered. Monitor LOC, MS and neuro s/s. Anticipate possible call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2186-02-04 00:00:00.000", "description": "Report", "row_id": 1555331, "text": "pmicu nursing progress note\ncardiac: bp 91-132/39-84 with a pulse of 95-124 afib, with occasional pvcs. k+ was 4.6. when pt is somulent and appearing more comfortable, pt's heart rate is in the 90's and low 100's, but when pt is more awake and moving around dr. heart rate becomes more elevated---to a rate of 124-128 afib. at approx 3P, when pt's heart rate was elevated to 128, a fluid bolus of 250cc of normal saline was given initially. and then when elevated heart rate continued an ekg was done, and then 5mg of lopressor iv x2 was given. heart rate slowed to a rate of 92 afib, but pt also asleep. pt also rec'd a fluid bolus of 250cc ns earlier this morning when pt had a bp of 93/ .\n" }, { "category": "Nursing/other", "chartdate": "2186-02-04 00:00:00.000", "description": "Report", "row_id": 1555332, "text": "addendum to above note\nresp: 2l nasal prongs with a resp rate of and sats of 96-99%. lung sounds clear and deminished in the rll. strong non-productive cough---cxr this morning appeared clear. 30sec periods of apnea--?? .\n\nid: temps of 99.4 ax, 98 ax, and 98.7ax. on unasyn. did receive a dose of vanco, which has since been dc'd as well as ceftriaxone. wbc was 12.8. purulent drainage noted from insertion site of old picc line--culture sent. urine and blood cultures still pending. gram stain from old picc site showed no microorganisms.\n\ngi: abdominal peg in place--tube feeds of probalance infusing at 20cc/hr. goal for tube feeds is 50cc/hr. minimal residuals obtained from peg. abdomin soft with + bowel sounds. npo---pt failed a previous speech and swollow study.\n\ngu: foley in place. urine output is approx 40-100cc/hr. bun is 27 and creat 1.0. urine had some sediment.\n\nneuro: pt somulent, on/off, throughout the day. face flushed, opens eyes to speech and intermittently verbally interacts with nurse and pt verbally can be understood, but other times speech is garbled and unable to understand pt. strong hands grasp, and will move feet and wiggle toes on request. once, pt became startled and raised right hand up into the air and sat bolt upright in bed, almost panicked, and stated that he was very dizzy(bp was fine). pt gently layed back in bed and was okay. pt was also singing while listening to music on PBS. pupiles 2mm-3mm, equal and briskly reactive to light. neuro by today.\n\ndaughter states prior to admission pt was walking without assistance from cane or walker--pt lives in an independent living center.\n\nskin: some scabbed over areas noted on right lower arm, around antecubital area, and skin pink---small amt of oozing from old picc site and cx sent. area covered with aquaphor and kerlex---pt found picking at site prior to area being covered. also scabbed over area on left ankle.\n" }, { "category": "Nursing/other", "chartdate": "2186-02-05 00:00:00.000", "description": "Report", "row_id": 1555333, "text": "NPN 1900-0700\nNeuro; Pt. alert, oriented x1-2, but found talking to self with no one in the room. Speech garbeled. MAE. Follows commands. Head CT neg.\n\nresp; LS clear and dim. at bases. Pt. has congested non productive cough. CXR ordered for AM. O2 on 2L NC with O2 sat 98% with good pleth. RR easy non labored.\n\nCV: VSS. BP 100's-130's-60's. HR 100's-130's A-fib with occ PVCs. Lopressor dose increased to 75 mg TID. Midnight dose held per parameters nut at 3AM HR noted to be as high as 140's, BP 130's/60's and Lopressor dose given with good effect. No edema.\n\nGI; NPO on TF via PEG. On Probalance TF at goal 50cc/hr with no residuals. Abd. soft, non tender, BS+. No BM at this time.\n\nGU; Urine output adequate. IVF NS at 100cc/hr x1L this shift.\n\nSkin; R arm AC area with ? old take burn and redness. DSD applied. Scabed area to L ankle.\n\nID: T max 99.7 AX. On Unasyn. vanco d/c'ed . Blood cx and urine cx on . No Tylenol this shift.\n\nSocial: Pt. is a full code. Visitors last evening.\n\nPlan; Cont. to follow cx data and WBC for appropriate abx. coverage. Monitor MS? infectious process.\n" }, { "category": "ECG", "chartdate": "2186-02-03 00:00:00.000", "description": "Report", "row_id": 263246, "text": "Atrial fibrillation with a rapid ventricular response. Ventricular premature\nbeat. Left anterior fascicular block. Poor R wave progression. Compared to the\nprevious tracing of rapid atrial fibrillation with ventricular\npremature beat is new and atrial premature beat is absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-02-03 00:00:00.000", "description": "Report", "row_id": 263247, "text": "Sinus rhythm with atrial premature beats. Left anterior fascicular block.\nPoor R wave progression. Consider anterior myocardial infarction, age\nindeterminate but could also be due to left anterior fascicular block. Compared\nto the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2186-02-06 00:00:00.000", "description": "Report", "row_id": 263244, "text": "Atrial fibrillation with rapid ventricular response\nLeft axis deviation - anterior fascicular block\nNonspecific ST-T wave changes\nPoor R wave progression\nSince previous tracing, faster ventricular rate present\n\n" }, { "category": "ECG", "chartdate": "2186-02-03 00:00:00.000", "description": "Report", "row_id": 263245, "text": "Atrial fibrillation with a rapid ventricular response. Left anterior fascicular\nblock. Non-specific ST-T wave changes. Poor R wave progression. Compared to\ntracing #2, no significant change.\nTRACING #3\n\n" } ]

[ { "category": "Radiology", "chartdate": "2145-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954614, "text": " 1:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with new left permacath plcmt\n\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess right Perm-A-Cath.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: Left Perm-A-Catheter remains in place\n with distal tip in the SVC. There is no pneumothorax. Mild cardiomegaly is\n stable. The lungs are clear. There is no pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-04-03 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 955882, "text": " 1:18 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o sbo\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with r/osbo\n REASON FOR THIS EXAMINATION:\n r/o sbo\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Abdomen, supine and erect.\n\n INDICATION: Possible small-bowel obstruction.\n\n Supine and erect abdominal films are obtained on at 13:23 hours. The\n patient has had recent surgery with a transplant kidney and with a ureteric\n stent in the transplant kidney. The bowel gas pattern is nonspecific. There\n is air in the bowel to the level of the rectosigmoid. Moderate amount of\n locular material seen, consistent with a fecal material. No unusual\n calcifications are seen. There is no evidence of pneumoperitoneum. The\n upright film shows some air in the soft tissues related to the right flank,\n which is presumably immediately post-surgical.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-26 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 954745, "text": " 10:46 AM\n RENAL TRANSPLANT U.S. Clip # \n Reason: S/P RLQ KID TX,EVAL FOR KID ANATOMY\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p renal transplant with proor kidney fuction.\n REASON FOR THIS EXAMINATION:\n kidney anatomy\n ______________________________________________________________________________\n FINAL REPORT\n RENAL TRANSPLANT ULTRASOUND, \n\n COMPARISON: None.\n\n INDICATION: 48-year-old male status post renal transplant with poor kidney\n function.\n\n FINDINGS: Examination is limited due to overlying bandage material. There is\n a transplant kidney identified within the right lower quadrant which measures\n 9.2 cm. No perinephric fluid collections are demonstrated. There is no\n evidence of hydronephrosis. Duplex Doppler interrogation of the renal\n transplant vasculature demonstrates normal arterial and venous waveforms.\n\n IMPRESSION: Limited but normal renal transplant ultrasound.\n\n These findings were discussed with Dr. at completion of the\n exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954963, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intrathoracic process\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with fever s/p kidney transplant (POD2) with SOB, resp in 50's\n\n REASON FOR THIS EXAMINATION:\n intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Fever.\n\n A single AP view of the chest was obtained at 05:15 hours and compared\n with the prior radiograph performed . There is relative under\n inflation of the lungs compared with the prior examination. Linear\n atelectasis at the right base persists. Linear atelectasis of the left base\n has developed. Dialysis catheter is unchanged in position.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-28 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 955008, "text": " 1:28 PM\n RENAL U.S. PORT Clip # \n Reason: please assess renal transplant arterial and venous flows and\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound with Doppler son status post transplant.\n\n INDICATION: 48-year-old male status post renal transplant with poor renal\n function. Please assess renal transplant arterial and venous flows and RIs.\n\n COMPARISON: Renal ultrasound .\n\n Grayscale: A transplanted kidney is identified in the right lower quadrant\n measuring 12.5 cm. There is no evidence of hydronephrosis. Lateral to the\n transplant kidney, there is again noted a non-vascular intermediate\n echogenicity structure measuring 15.8 cm x 12.2 cm x 16.6 cm. Imaging of this\n region is very limited.\n\n DUPLEX SON: The main renal artery and renal vein are patent. There is\n normal amount of vascularity within the transplanted kidney. Resistive index\n in the upper pole is 0.8, in the mid pole is 0.86, and lower pole is 0.81. The\n renal vein has normal venous waveforms.\n\n IMPRESSION:\n\n 1. No evidence of hydronephrosis in the transplanted kidney with\n resistive indices obtained within the kidney ranging from 0.8-0.86. These\n values are increased from study one day prior.\n\n 2. Heterogeneous collection adjacent to the transplanted kidney is slightly\n increased in size and cannot be fully characterized on this modality. CT may\n be utilized for further characterization of this collection if clinically\n warranted.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-27 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 954886, "text": " 12:16 PM\n RENAL TRANSPLANT U.S. PORT Clip # \n Reason: PT BLEEDING ASSESS FOR FLUID COLLECTION AROUND KIDNEY AND CHECK FOR FLOW\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with kidney tx\n REASON FOR THIS EXAMINATION:\n fluid collection around kidney and flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with kidney transplant. Assess for fluid\n collection around the kidney and flow.\n\n COMPARISON: Renal transplant ultrasound from one day prior.\n\n RENAL TRANSPLANT ULTRASOUND: The study was done portably. The patient was in\n a significant amount of pain during this study, and therefore the study was\n unable to be completed. A transplant kidney is identified in the right lower\n quadrant measuring 13.3 cm. There is no evidence of hydronephrosis. Lateral\n to the transplant kidney, there is a nonvascular intermediate echogenicity\n structure measuring 14 x 7.7 cm. Imaging of this region was very limited.\n\n The main renal artery and main renal vein are patent. There was a normal\n amount of vascularity in the transplant kidney. The resistive index in the\n mid pole was calculated at 0.85, although at this time the patient refused\n further imaging due to pain, and additional RIs and a corroboration of this RI\n could not be obtained.\n\n IMPRESSION: No evidence of hydronephrosis in the transplant kidney. Ill-\n defined structure adjacent laterally to the transplant kidney cannot be\n further characterized, a CT may be of value. Resistive indices could not be\n obtained given patient's pain and the need to terminate the study.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-28 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 955003, "text": " 12:21 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: ELEV LFT'S EVAL PORTAL AND HEPATIC FLOWS AND LIVER PARENCHYMA, PLEASE EVAL FOR ASCITES\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with kidney tx\n\n REASON FOR THIS EXAMINATION:\n Elev LFT's eval portal and hepatic flows and liver parenchyma\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Limited right upper quadrant ultrasound.\n\n INDICATION: 48-year-old male with renal transplant and elevated LFTs, please\n evaluate portal and hepatic flows and liver parenchyma.\n\n FINDINGS: The liver displays normal echotexture without focal mass\n identified. The main portal vein demonstrates normal hepatopetal flow without\n intraluminal thrombus identified. The hepatic veins are patent with normal\n flow. There is no intra- or extra-hepatic biliary ductal dilatation\n identified with the common bile duct measuring 4 mm. The gallbladder is\n normal in appearance without intraluminal stone or evidence of cholecystitis.\n\n IMPRESSION: Unremarkable examination of the liver and gallbladder.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954685, "text": " 10:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for pulmonary edema\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p kidney transplant, now with dimished breath sounds\n hypoxia\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diminished breath sounds and hypoxia, status post kidney\n transplant.\n\n PORTABLE CHEST: Comparison is made to chest x-ray from earlier the same day.\n Cardiomediastinal silhouette is unremarkable. Pulmonary vascularity is\n normal. Question is raised of a nodular opacity of the right mid lung field\n overlying the anterior fourth rib. Prominent bullous lesion is noted at the\n right cardiophrenic angle. Otherwise, the lungs appear grossly clear and\n there is no evidence of pleural effusion or pneumothorax. Left central venous\n catheter remains unchanged in position. Scattered atelectasis is seen\n bilaterally.\n\n IMPRESSION: Question raised of a nodular opacity in the right mid lung field,\n which may represent a confluence of shadows, however, further evaluation with\n PA and lateral films is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-28 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 955044, "text": " 7:40 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for evidence of FK toxicity\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p renal transplant\n REASON FOR THIS EXAMINATION:\n eval for evidence of FK toxicity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant, mental status changes. Evaluate\n for cyclosporine toxicity.\n\n COMPARISONS: None.\n\n TECHNIQUE: Multiplanar T1, T2 and diffusion-weighted imaging was obtained of\n the brain.\n\n MRI BRAIN WITHOUT CONTRAST: There are scattered foci of T2/FLAIR\n hyperintensity within the periventricular white matter which are nonspecific\n but likely represent chronic small vessel ischemic changes. The signal\n intensity of the brain parenchyma throughout is otherwise unremarkable. The\n posterior circulation brain parenchyma, including the occipital lobes\n bilaterally are unremarkable. No diffusion-weighted imaging abnormalities are\n identified to indicate acute ischemia.\n\n There is a 1.7 cm, multilobulated cystic structure within the posterior\n nasopharynx indicative of a Thornwaldt's cyst. Note is also made of slight\n heterogeneity of the marrow signal within the clivus.\n\n IMPRESSION:\n 1. No evidence of acute ischemia. Chronic small vessel ischemic changes. No\n findings indicative of posterior reversible leukoencephalopathy.\n 2. 1.8 cm cyst within the posterior nasopharynx indicating a Tornwaldt's\n cyst.\n 3. Slight heterogeneity of the signal intensity of the clivus which may\n represent sequela of chronic anemia or possibly a marrow infiltrative\n disorder.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954874, "text": " 10:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/p acute process\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with fever s/p kidney transplant (POD2) with SOB, resp in 50's\n REASON FOR THIS EXAMINATION:\n r/p acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Shortness of breath.\n\n FINDINGS: There is plate-like atelectasis in the right lower lung. The\n previously visualized question of a nodular opacity in the right mid lung is\n not visualized on today's study. There is no new infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-28 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 955013, "text": " 2:10 PM\n RENAL TRANSPLANT U.S. PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: please assess renal transplant arterial and venous flows and\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p renal transplant with proor kidney fuction.\n\n REASON FOR THIS EXAMINATION:\n please assess renal transplant arterial and venous flows and RI's\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound with Doppler son status post transplant.\n\n INDICATION: 48-year-old male status post renal transplant with poor renal\n function. Please assess renal transplant arterial and venous flows and RIs.\n\n COMPARISON: Renal ultrasound .\n\n FINDINGS: A transplanted kidney is identified in the right lower quadrant\n measuring 12.5 cm. There is no evidence of hydronephrosis. Lateral to the\n transplant kidney, there is again noted a non-vascular intermediate\n echogenicity structure measuring 15.8 cm x 12.2 cm x 16.6 cm. Imaging of this\n region is very limited.\n\n DUPLEX SON: The main renal artery and renal vein are patent. There is\n normal amount of vascularity within the transplanted kidney. Resistive index\n in the upper pole is 0.8, in the mid pole is 0.86, and lower pole is 0.81. The\n renal vein has normal venous waveforms.\n\n IMPRESSION:\n\n 1. No evidence of hydronephrosis in the transplanted kidney with\n intrarenal resistive indices within the 0.8-0.86 range. These values have\n increased since study one day previous.\n\n 2. Heterogeneous collection adjacent to the transplanted kidney is slightly\n increased in size and cannot be fully characterized on this modality. CT may\n be utilized for further characterization of this collection if clinically\n warranted.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2145-04-03 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 955915, "text": " 8:10 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? SBO\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n Field of view: 39\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p renal transplant with abdominal disention inability to pass\n stool. PO CONTRAST ONLY\n REASON FOR THIS EXAMINATION:\n Please evaluate fluid collection around tx kidney. Please only give PO\n contrast. Assess for evidence of SBO\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT abdomen and pelvis.\n\n INDICATION: Status post renal transplant with collection around the kidney.\n\n COMPARISON: No recent CT available for comparison.\n\n TECHNIQUE: A CT of abdomen and pelvis was performed with axial images taken\n from the lung bases to the symphysis pubis. Oral contrast only was\n administered.\n\n CT ABDOMEN FINDINGS: Note is made of coronary artery calcifications. A small\n left pleural effusion is noted. There is atelectasis in the right base. On\n the lung windows, a bulla is noted in the right base measuring 3 cm in maximum\n diameter. Below the diaphragm, the liver and spleen are unremarkable given\n that this is a non-contrast CT. A tiny area of high attenuation is identified\n in the liver adjacent to the gallbladder, which may represent a calcified\n granuloma. The gallbladder is normal. The adrenals are normal. The native\n kidneys are small and shrunken consistent with chronic renal failure and\n contain multiple tiny cysts. The pancreas appears unremarkable, but is\n difficult to evaluate fully on this non-contrast CT. The bowel where\n visualized is normal. No evidence of any small or large bowel obstruction.\n Within the right iliac fossa, the transplant kidney is identified. A ureteric\n catheter is identified which ends in the bladder. The bladder is empty.\n Around the kidney, a large heterogenous perinephric collection is identified.\n It is adjacent to the psoas muscle medially and extends laterally just beneath\n the abdominal wall. There are areas of high attenuation and the appearance is\n most likely consistent with recent hemorrhage. It extends lateral to the\n transplanted kidney. It measures 11.3 cm in maximum AP x 9.7 cm in maximum\n transverse x 16.2 cm in maximum craniocaudal dimensions. Some free fluid is\n also seen in the pericolic gutter on the right side. Sub-cm periaortic lymph\n nodes are identified. Surgical staples are seen over the skin from the\n previous recent surgery.\n\n CT OF PELVIS FINDINGS: The bladder is empty and contains the distal end of\n the ureteric stent. The bowel where visualized is normal. No free fluid.\n Bony windows reveal increased density consistent with chronic renal failure.\n Multiplanar reconstructions were essential in depicting the anatomy and\n identifying the pathology.\n (Over)\n\n 8:10 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? SBO\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n Field of view: 39\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Transplant kidney in right iliac fossa with ureteric stent in situ ending\n in the bladder.\n 2. Large heterogenous perinephric collection measuring 16 cm in maximum\n diameter and which most likely represents hemorrhage.\n 3. Small and shrunken native kidneys consistent with renal failure and which\n contains cysts.\n 4. Right basal atelectasis with left pleural effusion.\n 5. Increased density of bones consistent with chronic renal failure.\n\n" }, { "category": "ECG", "chartdate": "2145-03-27 00:00:00.000", "description": "Report", "row_id": 162707, "text": "Sinus tachycardia. Since the previous tracing of the rate is more\nrapid. There is otherwise, no significant change.\n\n" }, { "category": "ECG", "chartdate": "2145-03-25 00:00:00.000", "description": "Report", "row_id": 162708, "text": "Sinus rhythm. Probable left ventricular hypertrophy with poor R wave\nprogression. Compared to the previous tracing of no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-29 00:00:00.000", "description": "Report", "row_id": 1434805, "text": "NURSING\n VSS OVERNIGHT, NSR, NO ECTOPY. AFEBRILE. HCT STABLE, RECHECK\nAT 2200 2 POINTS HIGHER THAN PREVIOUS AND AM LABS STABLE. CVP LINE ATTACHED TO . NO CHANGE FROM THE LAST 24 HOURS.\n NEURO INTACT, ALERT AND ORIENTED X3. NO EPISODES OF UNRESPONSIVENESS. EEG YESTERDAY PER REPORT SHOWED MILD ENCEPHALOPATHY, NO SEIZURE ACTIVITY. MRI AT TO CHECK FOR PROGRAF TOXICITY. NO REPORT AVAILABLE AT THIS TIME. LEVEL DRAWN AT 0600 AND DOSE GIVEN AS ORDERED.\n FOLEY REMAINS IN PLACE. CONTINUES TO DRAIN VERY MINIMAL AMOUNTS OF BLOOD AND CLOTS, ONLY 15 ML OUT LAST 12/HRS. FLUSHED WITHOUT ANY INCREASE IN U/O. BM YESTERDAY AFTERNOON. ABDOMEN STILL DISTENDED, VERY FIRM, BUT IMPROVED FROM PREVIOUS NIGHT. BS HYPOACTIVE. REMAINS NPO. HEMODIALYSIS LAST NIGHT AT 2200, 3 LITERS OFF.\n CONTINUES TO HAVE PAIN, MEDCIATED WITH DILAUDID 1 MG Q 4 HRS WITH GOOD EFFECT.\n CONTINUE TO MONITER HEMODYNAMICS, HCT. RECHECK LYTES BETWEEN . CONTINUE TO MOINITER FOR PAIN AND MEDICATE PRN. ?OOB TODAY, CHAIR AND AMBULATION.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-28 00:00:00.000", "description": "Report", "row_id": 1434803, "text": "NURSING\n REMAINED IN SINUS TACHYCARDIA MOST OF THE SHIFT, EXCEPT AFTER BEING MEDICATED FOR PAIN. HR RANGED FROM 89-120'S, SINUS RHYTHM, OCCASIONAL PVC'S. BP ELEVATED 150-170'S. CVP LINE CONNECTED TO QUINTEN RANGED FROM . HCT INCREASED TO 30'S AT 4PM YESTERDAY, RECHECKED AT 8 PM LAST NIGHT, HCT WAS ALREADY DECREASED TO 24.2. ADDITIONAL 1 UNIT PRBC'S AND 1 UNIT PLASMA GIVEN. HCT POST TRANSFUSION THIS AM 22.3. DR AND DR NOTIFIED, ANOTHER ONE UNIT OF PRBC'S ORDERED.\n FOLEY IN PLACE DRAINING 15 ML OVER THE SHIFT. BRIGHT RED BLOOD AND CLOTS. IRRIGATED X2 WITH NO INCREASE IN URINE OUTPUT. TAKING IN PO'S, SIPS OF CLEARS WITH PO MEDICATIONS. NO NAUSEA.\n ABDOMEN EXTREMELY TENSE, DISTENDED, HARD. POSITIVE BOWEL SOUNDS, NO FLATUS.C/O SEVERE PAIN. PAIN MEDS DC'D BY TRANSPLANT TEAM. ALLOWED TO GIVE DILAUDID 1 MG X2 OVERNIGHT FOR ABDOMINAL AND BACK PAIN WITH FAIR EFFECT AFTER CALLS TO TRANSPLANT FELLOW. C/O NUMBNESS IN RIGHT THIGH. TEAM AWARE. POSITIVE RIGHT FEMORAL, POPLITEAL, AND LOWER EXTREMITY PULSES. EXAMINED BY MD'S.\n RESPIRATORY RATE HAS BEEN 30-40 CONSISTENTLY SINCE ADMIT. DIFFICULT TO OBTAIN AN O2 SAT. WHEN ABLE TO READ ONE, SAT HAS BEEN 96-99% ON 2 LITERS NASAL CANNULA. LUNGS CTA, DIMINISHED BASES. NO COUGH.\n NO FURTHER EPISODES OF UNRESPONSIVENESS. ALERT AND ORIENTED X3. COMMUNICATING APPROPRIATELY, ABLE TO MAKE NEEDS KNOWN, OCCASIONALLY VERY DEMANDING. MOVING ALL EXTREMITIES.\n CONTINUE TO MONITER HEMODYNAMICS, RECHECK HCT POST TRANSFUSION. HEMOLYSIS LABS TO BE DRAWN NOW. CONTINUE TO MONITER ABDOMINAL GIRTH, RIGHT LE PULSES. MONITER PAIN LEVELS AND MEDICATE WHEN TRANSPLANT TEAM ALLOWS. OFFER EMOTIONAL SUPPORT TO FAMILY AND PATIENT.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-28 00:00:00.000", "description": "Report", "row_id": 1434804, "text": "FOCUS; STATUS UPDATE\nDATA;\nPATIENT ALERT AND ORIENTEDX3. C/O BACK PAIN AND SOME ABD PAIN WHICH HAS BEEN SLIGHTLY RELIEVED BY DILAUDID PRN. HE IS NEVER PAIN FREE, HOWEVER. NEUROLOGY CONSULT AND EEG DONE AT BEDSIDE TO R/O SEIZURE ACTIVITY BASED LAST TWO EPISODES OF UNRESPONSIVENESS YESTERDAY. MILD ENCEPALOPATHY SEEN.\n\nTRANSFUSED WITH 2 UNITS PRBC AND 1UNIT FFP.\n\nLUNGS CONTINUE WITH SLIGHT CRACKLES AT THE BASES. SATS 98-99% ON 4LNC O2. HE DENIES SOB AND RR NOW IN THE 20'S-30'S. HE CONTINUES TO TAKE SHALLOW BREATHS AND UNABLE TO DO INCENTIVE SPIROMETRY ADEQUATELY DUE TO INABILITY TO DEEP BREATHE.\n\nABDOMEN MORE FIRM AND DISTENDED WITH HYPOACTIVE BOWEL SOUNDS. ABD/LIVER/RENAL U/S DONE TODAY. CONTINUES NPO ALTHOUGH SIPS WITH MEDS. JP WITH SANG DRAINAGE, SMALL AMOUNTS. DULCOLAX PR WITH RESULTS.\n\nMNINIMAL TO NO URINE OUTPUT. AWAITING HD.\n\nPLAN:\nMRI TONIGHT. HD TONIGHT. F/U LABS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-27 00:00:00.000", "description": "Report", "row_id": 1434802, "text": "FOCUS; STATUS UPDATE\nDATA;\nPT ARRIVED IN SICU FROM 10 AFTER UNRESPONSIVE EPISODE ON 10. AT THE TIME HE WAS TACHYCARDIC AND RR UP TO 50. HE C/O OF SOB AT THE TIME. HIS MENTAL STATUS CAME BACK TO NORMAL SOON AFTER BUT HE SHOWED A HCT DROP TO 20 AND HAD SANG. DRAINAGE FROM HIS JP. HE WAS TRANSFERRED TO SICU FOR FURTHER MONITORING. HE WAS ALERT AND ORIENTED X3 ON ARRIVAL. HE AGAIN HAD SIMILAR EPISODE TODAY AT 1615 WHILE ON HD AND RECEIVING UNIT OF BLOOD. HIS EYES ROLLED BACK AND HE BECAME UNRESPONSIVE, AND WAS ALERT WITHIN A FEW MINUTES BUT LETHARGIC FOR ABOUT 15MIN. HIS LAST DOSE OF OXYCODONE WAS GIVEN AT 1400.\n\nLUNGS HAVE BEEN CLEAR BILATERALLY AND SAT ALTHOUGH EXTREMELY DIFFICULT TO OBTAIN HAS BEEN MID TO HIGH 90'S WHEN . HE HAD ABG DONE AT TIME OF LATEST EPISODE WHILE ON A NONREBREATHER MASK AND PAO2 WAS 366, HE SHOWED A RESP ALKALOSIS. HE IS CURRENTLY ON 4LNC O2 WITHOUT SOB. AT TIMES HIS RR UP TO 40'S. HE WAS FEBRILE TO 101.4 AND BC SENT FROM QUINTON.\n\nHE COMPLAINS OF ABD PAIN AND BACK PAIN ALL THE TIME. HIS ABD IS SLIGHTLY FIRM AND DISTENDED WITH POSITIVE BS. IT IS VERY TENDER TO THE TOUCH. HE RECEIVED OXYCODONE X2 WHICH IS NOW DISCONTINUED PER TRASPLANT. HE RECEIVED ONE DOSE OF DILAUDID THIS PM. HIS ABD INCISION ID D/I WITH STAPLES INTACT. JP CONTINUES TO PUT OUT SMALL AMOUNTS SANG. DRAINAGE. HE HAS RECEIVED 3UNITS OF PRBC AND 2UNITS OF FFP. HIS HCT IS NOW STABLE TO 31.\n\nHD DONE TODAY UNTIL EPISODE OF UNRESPONSIVENESS AND THEREFORE TREATMENT WAS TERMINATED EARLY. NET FLUID REMOVAL WAS 400ML. HIS URINE OUTPUT HAS BEEN MINIMAL AND DARK RED/CLOTTY.\n\nGIRLFRIEND AT BEDSIDE AND SUPPORTIVE. PT. IS VERY DEMANDING AT TIMES, EMOTIONAL SUPPORT PROVIDED AS WELL AS LIMIT SETTING AT TIMES.\n\nPLAN;\nF/U COAGS AFTER FFP. DISCOURAGE NARCOTICS PER TRANSPLANT DUE TO RESP STATUS.\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-26 00:00:00.000", "description": "Report", "row_id": 1434801, "text": "Nursing Progress Note\n48 yo male with PMH CRI, CHF, HIV, neuropathy, Hep C, HTN, s/p kidney transplant on . Pt was taken back to the OR last evening for exploration of a venous bleed (lrg output from JP site). No sig findings. K 8.4 after OR. Pt transferred to TSICU for HD and close monitoring.\n\nPt had HD from 0130-0345 this shift. AM labs to be sent out at 0600.\n\nNeuro: Pt A+Ox3. Arousing to voice. MAE, all normal strength. Pt has dilaudid PCA for pain control with good effect.\n\nCV: NSR, no ectopy. HR 50-70's. SBP 100-160's. Per surgery team, SBP of 170's is baseline. +PP. Pt recieved one unit PRBC during HD.\n\nResp: pt currently SV on RA. Sats 98-100%. o2 pleth difficult to trace. RR low 20's. LSCTAB. Strong cough and gag.\n\nGI: Abd soft, nd. Tender at incision site on L flank. +BS. No BM this shift. Pt currently tolerating CL diet.\n\nGU: Foley draining scant amts red urine with clots. UOP <5ml/hr.\n\nEndo: FS 148. No coverage at this time.\n\nID: Afebrile. Pt cont on levo and bactrim.\n\nSkin: Incision to L abd covered with original OR DSG. Dsg saturated with sanguinous drainage. HO aware. Dsg reinforced. Drain to LCWS, sm amts sanguinous fluid.\n\nSocial: No phone calls or visits this shift.\n\nPlan: Maintain SBP <170. Follow up with pending lab results. Replete lytes as needed. Monitor drainage amt from incision. Tx to floor.\n" } ]

[ { "category": "Radiology", "chartdate": "2134-03-07 00:00:00.000", "description": "INTRO PERC TRNASHEPATIC STENT", "row_id": 783487, "text": " 7:20 PM\n PTC Clip # \n Reason: ?biliary drainage\n Contrast: CONRAY Amt: 65\n ********************************* CPT Codes ********************************\n * INTRO PERC TRNASHEPATIC STENT PERC TRANSHEPATIC CHOLANGIOGRA *\n * -51 MULTI-PROCEDURE SAME DAY CATH/STENT FOR INT/EXT BILIARY *\n * PERC TRANSHEPATIC CHOLANGIOGRA CATHETER, DRAINAGE *\n * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with post ERCP pancreatitis, presumed cholangitis.\n REASON FOR THIS EXAMINATION:\n ?biliary drainage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 80-year-old male transferred from another hospital with recent\n CT showing gallstone and CBD stone presents with obstructive jaundice,\n lethargy and hypotension. ERCP was unsuccessful. Percutaneous transhepatic\n biliary drainage was requested for acute cholangitis.\n\n RADIOLOGISTS: The procedure was performed by Drs. and \n with the attending radiologist, Dr. being present for the entire\n procedure.\n\n PROCEDURE AND FINDINGS: The patient was placed supine on the angiographic\n table and the abdomen was prepped and draped in the usual sterile fashion. 1%\n Lidocaine was applied to the puncture site and a 21-gauge Chiba needle was\n advanced from the 10th intercostal space at mid-axillary line toward the\n subxyphoid region. Injection of nonionic contrast through the needle\n opacified the dilated biliary ducts. A second needle was advanced through the\n same entry site into a posterior branch of the right hepatic duct and a .018\n wire was advanced into the hepatic duct and common bile duct. The needle was\n exchanged for a 4-French introducer and injection of contrast through the\n sheath opacified tortuous, markedly dilated CBD, as well as dilated right and\n left biliary ducts, cystic duct and gallbladder. There are at least 2 large\n filling defects in the distal CBD representing choledocholithiasis. The\n gallbladder is full of many filling defects of different sizes. A .018 wire\n was placed into the CBD again and the introsducer was exchanged for a 6-\n French sheath. The .018 wire was exchanged for a .035 Amplatz wire. A 6-\n French -tip sheath was advanced over the wire into the CBD. The wire and\n a 5-French Kumpe catheter was advanced through the CBD into the duodenum.\n Injection of contrast through the catheter showed duodenal mucosal patterns.\n The sheath was removed and an 8 French biliary draining tube was placed over\n the wire with the pigtail coiled in the duodenum and the side holes in the\n biliary duct. Catheter cholangiogram showed the side hole is in proper\n position. The catheter was connected to a drainage bag and secured to the\n skin with a 0-prolene stitch.\n\n The patient tolerated the procedure with no complications. The patient's\n systolic blood pressure increased from 70 to 80 mmHg prior to the drainage to\n (Over)\n\n 7:20 PM\n PTC Clip # \n Reason: ?biliary drainage\n Contrast: CONRAY Amt: 65\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 110 mmHg after the catheter placement.\n\n MEDICATIONS: Patient was intubated with IV Propofol for sedation. The patient\n was on phenelephrine drip to maintain the blood pressure and also received\n Flagyl, Levofloxicin and vancomycin intravenously.\n\n IMPRESSION: Successful percutaneous transhepatic biliary external/internal\n drainage.\n\n" }, { "category": "Radiology", "chartdate": "2134-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 783486, "text": " 6:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT tube and CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with biliary pan and cholangitis\n REASON FOR THIS EXAMINATION:\n ETT tube and CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Biliary pain. Cholangitis. Assess ETT.\n\n SUPINE AP CHEST, 1 VIEW: There are no prior studies for comparison. Study is\n slightly limited by motion and respiratory artifact. There is an ETT 5.3 cm\n above the carina. The heart is enlarged. There is no definite CHF. There is\n bibasilar atelectasis. I doubt the presence of underlying pneumonia. There is\n no large pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2134-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 783684, "text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate ?CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cholangitis, appears to be aspirating clinically.\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: An 80-year-old male with clinical aspiration. Assess\n for interval ______ .\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: .\n\n FINDINGS: There is stable cardiac enlargement. The mediastinal contours are\n within normal limits. The pulmonary vasculature is not engorged. In the\n interval, there has been improvement of the previously apparent right basilar\n opacity. There is persistent left lower lobe collapse/consolidation, as well\n as a small left pleural effusion.\n\n IMPRESSION:\n 1. Interval improvement in appearance of right basilar infiltrate.\n 2. Persistent collapse/consolidation of left lower lobe with a small left\n pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2134-03-09 00:00:00.000", "description": "CHANGE PERC BILIARY DRAINAGE CATHETER", "row_id": 783597, "text": " 8:58 AM\n BILI STONE REM Clip # \n Reason: impacted stone in CBD, s/p failed ERCP\n Contrast: CONRAY Amt: 40\n ********************************* CPT Codes ********************************\n * CHANGE PERC BILIARY DRAINAGE C -58 SERVIC BY SAME MD DURING POST OP *\n * -51 MULTI-PROCEDURE SAME DAY CHALNAGIOGRAPHY VIA EXISTING C *\n * -58 SERVIC BY SAME MD DURING POST OP -51 MULTI-PROCEDURE SAME DAY *\n * BIL DUCT STONE EXT PERC OR T-T -58 SERVIC BY SAME MD DURING POST OP *\n * -53 INCOMPLETE/UNSCUCCESSFUL CHANGE PERC TUBE OR CATH W/CON *\n * TUBE CHOLANGIOGRAM STONE REMVOAL VIA T-TUBE OR BA *\n * CATH, TRANSLUM ANGIO NONLASER CATHETER, DRAINAGE *\n * C1769 GUID WIRES INCL INF C1773 SNARE-RETRIEVAL DEVICE INSERT *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with chr AFib, cholangitis, thrombocytopenia.\n REASON FOR THIS EXAMINATION:\n impacted stone in CBD, s/p failed ERCP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 80 y/o male status post PTBD for acute cholangitis secondary for\n choledocholithiasis.\n\n RADIOLOGISTS: Dr. , Dr. and Dr. with attending\n radiologist Dr. being present during the entire procedure.\n\n PROCEDURE/FINDINGS: The risks and benefits were explained to the patient's\n daughter and consent was obtained.\n\n The patient was placed supine on the angiographic table and the procedure was\n performed under MAC anesthesia.\n The right abdomen was prepped and draped in sterile fashion. .035 Amplatz\n wire was placed into right biliary drainage catheter with the tip in the\n duodenum. The catheter was removed and an 8 French tip sheath was placed\n over the wire into the common bile duct. Injection of contrast through the\n sheath demonstrated a tortuous and extremely dilated common bile duct, common\n hepatic duct and a moderately dilated biliary tree. Cystic duct and the\n gallbladder are opacified and showed many filling defects in the gallbladder.\n There are large filling defects in the common bile duct representing\n choledocholithiasis. The ampulla was dilated using 12 mm x 4 cm balloon.\n Contrast showed free flow from the common bile duct into the duodenum. There\n is a large duodenal diverticulum with its neck near the ampulla. A stone\n removal basket was placed through the sheath into the common bile duct and\n attempted stone breaking was made but unsuccessful. Repeat cholangiogram\n demonstrated a patent common bile duct and duodenal junction. 10 French\n biliary draining catheter was placed over the wire with the tip in the\n duodenum and the side holes in the common bile duct and right hepatic duct.\n Injection of contrast through the catheter showed the proper position of the\n catheter side holes. The catheter was secured to the skin using a 0 prolene\n stitch and connected to a draining bag.\n\n (Over)\n\n 8:58 AM\n BILI STONE REM Clip # \n Reason: impacted stone in CBD, s/p failed ERCP\n Contrast: CONRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The patient tolerated the procedure well with no complications.\n\n IMPRESSION: Balloon dilatation of the junction of common bile duct and\n duodenum but unsuccessful stone removal due to the large size of the stone.\n\n\n" }, { "category": "Echo", "chartdate": "2134-03-09 00:00:00.000", "description": "Report", "row_id": 73371, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Congestive heart failure. Murmur.\nBP (mm Hg): 108/52\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 08:54\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 dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is markedly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is severely dilated. There is mild regional left\nventricular systolic dysfunction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is moderately dilated. The ascending aorta is\nmoderately dilated. The aortic arch is moderately dilated.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is no\naortic valve stenosis. Severe (4+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\nmoderate mitral annular calcification. There is mild thickening of the mitral\nvalve chordae. Moderate (2+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve leaflets are moderately thickened.\nModerate to severe [3+] tricuspid regurgitation is seen. There is severe\npulmonary 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 dilated. The right atrium is markedly dilated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis moderately to severely dilated. There is mild regional left ventricular\nsystolic dysfunction with anterosepetal hypokinesis/akinesis and apical\nakinesis. Right ventricular chamber size and free wall motion are normal. The\naortic root is moderately dilated. The ascending aorta is moderately dilated.\nThe aortic arch is moderately dilated. The aortic valve leaflets are\nmoderately thickened. Moderate to severe (3+) aortic regurgitation is seen.\nThe mitral valve leaflets are moderately thickened. Moderate (2+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are moderately thickened. Moderate to severe [3+] tricuspid\nregurgitation is seen. There is severe pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2134-03-11 00:00:00.000", "description": "Report", "row_id": 1487437, "text": "S/MICU Nursing progress Note\n Neuro: Pt is alert, oreinted to place and person at times forgets where he is and is easily reoriented. Lethargic, moving all extremites. speech thick can not always pronouce his words. concerned about his wife, requesting to call his daughter this morning.\n Cardiac: Hr 90-110afib with rare to frequent PVC's BP stable 100-120/80's\n Respiratory; on @ liters nasal cannula with O2 sat 98's RR 20 to high 20's but deep and labored at times. He denies any SOB but with have to stop drinking sips of water to get his breath. BS coarse on the right and clear on the left. Mild CPT given to the right, encouraged cough and deep breath with some results but pt is swallowing the sputum.\n GI: biliary drain clamped at last night as ordered by Dr. . pt denies any pain, nausea,\n ID: temp 97 max during the night. bilary fluid and blood cultures + for VRE, repeated the blood cultures x2 this morning. in on contact precautions.\n : ? transfer back to today.\n" }, { "category": "Nursing/other", "chartdate": "2134-03-09 00:00:00.000", "description": "Report", "row_id": 1487433, "text": "MICU/SICU NPN HD #3\nS: \"Am I going to make it?\"\n\nO:\n\nNeuro: pt is A&Ox1-2, forgetful, reorients with verbal cueing for brief periods, denies pain, OOB to chair with 2 mod assist x3h, MAEW, collowing commands\n\nResp: SpO2 99% on 50% face tent, had been 97-99% on 3L NP, LS CTA today\n\nCV: continues in AF 90-120 with occasional to frequent PVCs, and occasional rate spikes into 130's with activity, please see flowsheet for data, skin is C/W/D/I except for RUQ drain site\n\nGI/GU: abd is soft, NT/ND, BS present, remains NPO, pt underwent percutaneous dilitation and stenting of CBD with stone ablation and repeat drain (T-tube) placement under fluro today, T-tube draining mod amts dark bilious fluid with sediment, pt voiding qs via cath\n\nLines: #16 angio in right FA and #22 angio in left hand\n\nID: afebrile, continues on Levofolxacin, Vancomycin and Flagyl\n\nA:\n\nhigh risk for infection r/t percutaneous drain\naltered nutrtion, LBR r/t poor caloric intake > 5 days\nhigh risk fo rinjury r/t poor mobility, generalized weakness\n\nP:\n\ncontinue to monitor hemodynamic stability, continue abx as ordered, nutrition c/s and inititate nutrtional support as reccomended, activity progression, surgical c/s, cm c/s to intitiate post acute care planning\n" }, { "category": "Nursing/other", "chartdate": "2134-03-10 00:00:00.000", "description": "Report", "row_id": 1487434, "text": "cns- pt continues to be confused as to time/circumstance. says hospital when asked where he is. maew, peerl, follows commands.\n\ncv- afib with occ pvs-rate 90's to 110's with occ burst into 130-140's. afebrile, vss. see flowsheet for details.\n\nresp- lungs essentially clear, though occ crs uppers. clears with strong cough. prod of white-yellow sputum. sats well on 3l nc high 90's to 100.\n\ngi- clear liquids. tol small amts well. diet to be advanced today. abd soft, round, bt hypo. large loose stool heme+ x1. rectal bag in place.\n\ngu- amber/icteric with sediment urine output via condom cath.\n\nmsi- grossly intact, though mult older ecchymotic areas to arms. red area on coocyx. attempted to keep pt off back much of noc.\n" }, { "category": "Nursing/other", "chartdate": "2134-03-10 00:00:00.000", "description": "Report", "row_id": 1487435, "text": " 4 ICU NPN 1100-1900\n\n Given lopressor 2.5mg IV X2 earlier for rate control with some transient decrease in HR. SBP also transiently dropped to 80's after second dose. Started back on PO lopressor & metroprol without decrease in SBP. Remians in AF. HR presently running 90's with occas PVC's. SBP 107-120's.\n Biliary drain cont to put out bile material. Flushed Q6 hrs. denies pain.\n Developed coarse BS with crackles at bases. Lasix 10 mg X1 with good effect. CXR-no failure. Lips dry c/o thirst. Equal fld balance\n Started on soft solids. Appitite fair. Has impaired gag reflex. Coughs aaat X's after drinking liquids.\n A&O most of the day. Easily reoriented. Dtr in to visit. She was updated on pt's condition by Dr. .\n Pt will probably be transferred back to for further care. Page 2 done on care web & will need to be updated prior to transfer.\n" }, { "category": "Nursing/other", "chartdate": "2134-03-10 00:00:00.000", "description": "Report", "row_id": 1487436, "text": "NPN addendum\n\n BC & biliary fld cultures positive for VRE. Placed on contact precautions.\n" }, { "category": "Nursing/other", "chartdate": "2134-03-07 00:00:00.000", "description": "Report", "row_id": 1487429, "text": " 4 ICU nursing admit note:\n 80 y/o male transfered from GI suite s/p ERCP attempt. Pt was intubated for sedative purposes..required neo to support BP. Sent to ICU for further care.\n Pt was transfered from for this procedure. Had been admitted there 4 days ago s/p fall and ?jaundice.\n Allergies: PCN\n PMHX: Afib..divertic..s/p colectomy d/t bleed\n aortic insuff. Recent pneumonia..dc'd from hospital\nTakes care of wife at home who has dementia.\nDaughter is spokesperson\n Systems Review:\n Respiratory: Intubated and vented..PSV..suctioned for thick white sputum rr 14-18..50%\n Cardiac: BP 60-90's..aline place..neo gtt increased to maintain bp of 90's (baseline) Hr 100-120's af.chronic..\n Sedation: Pt clearly uncomfortable..increased propofol..effective..but does drop bp.\n Lines: #16 r arm..#22 left arm\n GI: Plan is to take pt to interventional radiology for percutaneous drain tonoc.\n" }, { "category": "Nursing/other", "chartdate": "2134-03-08 00:00:00.000", "description": "Report", "row_id": 1487430, "text": "RN PROGRESS NOTE\nPT RETURNED FROM LS AT2030 FOLLOWING DRAIN PLACEMENT. TOLERAATED PROCEDURE WELL. B/P 120'S SYSTOLIC. NEO TO .5MCG. PT 2CC PROPOFOL BOLUSES X3 FOR AGITATION DURING PROCEDURE. NO ISSUES WITH RESP STATUS DURING PROCEDURE. DR. TO FAMILY MEMBERS PROCEDURE.\nAT 2200 PT EXTUBATED DUE TO IMPROVING RESP STAUTS CURRENTLY ON FACE TENT SAT 100% PRODUCTIVE COUGH. PT DOSING INTERMITTENTLY\n" }, { "category": "Nursing/other", "chartdate": "2134-03-08 00:00:00.000", "description": "Report", "row_id": 1487431, "text": "MICU/SICU NPN HD #2\nS/O:\n\nNeuro: pt is alert, orientedx2, confused at times, calling out, reorients easily, denies pain, MAEW, OOB to chair with 2 max asist x 6h\n\nResp: SpO2 91-99% on 3L NP, LS CTA\n\nCV: AVSS, AF 90's to 100's with occasional PVC's. please see flowsheet for data\n\nSkin: C/W/D/I\n\nGI/GU: abd soft, NT/ND, NPO, hypoactive BS, RLQ has T-tube draining dark bilious, icteric fluid with \"coffee grounds\" sediment, voiding qs via cath\n\nLines: #20 angio left hand, #16 angio right FA\n\nFEN: NPO, D51/2NS with 20 mEq KCl infusing at 125cc/h\n\nID: afebrile, on Vanco, Flagyl and Levaquin\n\nA:\n\nhigh risk for injury r/t generalized weakness\nrisk for infection r/t biliary obstruction, biliary drain\naltered nutrition, LBR r/t poor caloric intake > 5 days\n\nP:\n\ncontinue ot monitor hemodynamic stability, NPO for proceedure tomorrow, nutrtion c/s, continue abx as ordered\n" }, { "category": "Nursing/other", "chartdate": "2134-03-09 00:00:00.000", "description": "Report", "row_id": 1487432, "text": "cns- pt cont to be somewhat confused, though pleasant. follows commands, peerl, maew. pt is not understanding of circumstances/need for tx/hospitalization.\n\ncv- afib rate 90-120 with occ bursts into 130's, occ pvcs. afebrile. vss. plt count cont to be very low- no plan to give plts unless bleeding noted.\n\nresp- lungs somewhat crs in uppers. pt has strong cough, productive for white/yellow sputum. sats high 90's to 100 on 3l nc.\n\ngi- abd soft, bt hypo. npo for ? ercp today.\n\ngu- icteric urine with clots/sediment via condom cath. pt not foleyed due to low plt count.\n" } ]

[ { "category": "Echo", "chartdate": "2156-10-11 00:00:00.000", "description": "Report", "row_id": 82183, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p cardiac arrest\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 112/64\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 08:06\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: Normal LV wall thickness. Severely dilated LV cavity. Severely\ndepressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen. Mildly dilated RV cavity. Borderline normal\nRV systolic function.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Mild PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity is severely dilated. Overall left ventricular systolic\nfunction is severely depressed (LVEF= 15-20 %). The right ventricular cavity\nis mildly dilated with borderline normal free wall function. The aortic root\nis mildly dilated at the sinus level. The aortic arch is mildly dilated. The\naortic valve leaflets are mildly thickened (?#). There is no aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Mild to moderate (+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. The pulmonary artery systolic pressure could not be determined.\nThere is no pericardial effusion.\n\nIMPRESSION: Severely dilated left ventricle with severe global left\nventricular hypokinesis. The right ventricle is not well seen but is probably\nmildly dilated and borderline hypokinetic. Mild to moderate mitral\nregurgitation.\n\nCompared with the prior study (images reviewed) of , overall left\nventricular systolic function has substantially worsened. The right ventricle\nappears dilated and hypokinetic on the current study. Pulmonary artery\npressures could not be estimated on the current study.\n\n\n" }, { "category": "ECG", "chartdate": "2156-10-10 00:00:00.000", "description": "Report", "row_id": 207311, "text": "Sinus rhythm. Right axis deviation. Right bundle-branch block. First degree\nA-V delay. Frequent unifocal right bundle-branch block premature ventricular\ncontractions, new compared to previous tracing of and now in a\nbigeminal pattern.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-10-10 00:00:00.000", "description": "Report", "row_id": 207312, "text": "Sinus rhythm with first degree A-V delay. Intraventricular conduction delay.\nRight axis deviation. Non-specific ST-T wave flattening. Other than sinus\nrate slowing, no significant change compared to previous tracing of .\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2156-10-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1256855, "text": " 8:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICh?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man found down\n REASON FOR THIS EXAMINATION:\n ICh?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PBec SUN 9:37 PM\n no acute intracranial process\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down. Evaluate for intracranial hemorrhage.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: Non-contrast axial images obtained through the brain. Coronal and\n sagittal reformations provided.\n\n FINDINGS: There is no evidence of hemorrhage, edema, large mass, mass effect\n or acute infarct. Ventricles and sulci are normal. No fracture identified.\n The mastoid air cells, middle ear cavities and visualized paranasal sinuses\n are clear. No soft tissue swelling identified.\n\n IMPRESSION: No acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256858, "text": " 11:59\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess after lost pulses\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man s/p VT and shock and CPR\n REASON FOR THIS EXAMINATION:\n assess after lost pulses\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Radiographs dating between and :\n Marked cardiomegaly is accompanied by pulmonary vascular engorgement and\n combined alveolar and interstitial edema as well as a small right pleural\n effusion. No visible pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-10-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1257198, "text": " 9:31 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 42cm right picc. \n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 42cm right picc. \n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC. Evaluate for placement.\n\n COMPARISONS: Chest radiograph . CTA chest .\n\n FINDINGS: A new right PICC is curled in the mid SVC. The length of the\n curled portion is 4.8 cm.\n\n There is mild peribronchial cuffing and intersitial prominence consistent with\n mild pulmonary edema. Mild bibasilar atelectasis is stable. There is no\n consolidation, pleural effusion, or pneumothorax. The cardiac size is at the\n upper limits of normal. The mediastinal contours are unchanged.\n\n IMPRESSION:\n 1. Right PICC curled in the SVC with approximately 4.8 cm of redundant\n catheter pointing superiorly.\n 2. Stable bibasilar atelectasis.\n\n Results were discussed with of the IV team at 9:50 a.m. on \n via telephone by Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2156-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256854, "text": " 8:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 49M with hypotension\n REASON FOR THIS EXAMINATION:\n Acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension.\n\n COMPARISONS: .\n\n FINDINGS: Portable AP chest radiographs were obtained. The central pulmonary\n vasculature is slightly more pronounced compared with the prior exam in .\n Linear opacities at the right base are most compatible with atelectasis. Mild\n cardiomegaly is unchanged. There is no new consolidation, effusion or\n pneumothorax. A rim calcified lesion in the right upper quadrant is\n compatible with previously seen calcified liver cyst.\n\n IMPRESSION: Slight prominence of the central pulmonary vasculature is\n compatible with pulmonary venous hypertension. No overt pulmonary edema or\n other acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2156-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256956, "text": " 9:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: is there pneumonia?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with new fever\n REASON FOR THIS EXAMINATION:\n is there pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever, to assess for pneumonia.\n\n FINDINGS: In comparison with the study of , there is continued\n enlargement of the cardiac silhouette in a patient with intact midline sternal\n wires. There is an area of suspected increased opacification in the right mid\n zone, though this also is in region where there is overlap of the scapula. In\n view of the clinical symptoms, the possibility of developing consolidation\n would have to be considered. If clinically possible, a repeat study with the\n scapula displaced over the chest could be obtained to determine whether this\n is a true finding.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-10-11 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1256862, "text": " 9:01 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Presence of DVT\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49M with h/o HIV on HAART presents with hypotension, bradycardia, hypoxemia\n REASON FOR THIS EXAMINATION:\n Presence of DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with history of HIV on HAART, presenting with\n hypotension, bradycardia, and hypoxemia, evaluate for DVT.\n\n COMPARISONS: None.\n\n TECHNIQUE: Duplex Doppler examination was performed on the right and left\n lower extremity.\n\n On the left, there is normal augmentation and compression of the common\n femoral, superficial femoral, and popliteal veins. The left posterior tibial\n veins compress normally and demonstrate normal flow. The left peroneal veins\n were not visualized.\n\n On the right, complete evaluation is limited by the presence of a central\n venous line and overlying bandages. The common femoral vein and proximal\n superficial femoral vein could not be evaluated. However, there was normal\n compression and flow seen within the mid SFV, distal SFV, and popliteal veins.\n The right peroneals and posterior tibial veins demonstrate normal\n compressibility and vascular flow. The most superior portion of the common\n femoral vein demonstrated normal flow without evidence of a thrombus.\n\n IMPRESSION:\n 1. Within the limitations of this exam, there is no deep vein thrombosis seen\n within the right or left extremity.\n 2. Nonvisualization of the left peroneal veins.\n\n" }, { "category": "Radiology", "chartdate": "2156-10-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1256902, "text": " 6:38 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please evaluate for proper line placement and possibility of\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with hypotension and new left internal jugular central line\n placement\n REASON FOR THIS EXAMINATION:\n Please evaluate for proper line placement and possibility of pneumothorax\n ______________________________________________________________________________\n WET READ: MJMgb MON 8:05 PM\n Left IJ catheter terminates in mid SVC. No PTX. Pulmonary vascular\n engorgement and interstitial edeam mildly improved from 12:06 a.m.. Moderate\n cardiomegaly, unchanged. No large pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left IJ catheter that extends to the mid portion of the SVC.\n No evidence of pneumothorax. The degree of pulmonary vascular congestion is\n less prominent than on the previous study. Moderate cardiomegaly persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-10-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1256999, "text": " 4:01 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for evidence of pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with fevers, ?PNA on portable film\n REASON FOR THIS EXAMINATION:\n eval for evidence of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible pneumonia.\n\n FINDINGS: In comparison with study of , the patient has taken a much\n better inspiration. There is still mild asymmetry of the mid portion of the\n lungs with more opacification on the right. This could still represent a\n focus of clearing consolidation in the appropriate clinical setting.\n\n The remainder of the study shows continued enlargement of the cardiac\n silhouette with basilar atelectatic or fibrotic streaks. No vascular\n congestion.\n\n Densely calcified lesion in the right upper quadrant is seen as on the CT\n examination of .\n\n" }, { "category": "Radiology", "chartdate": "2156-10-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1257200, "text": " 9:53 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: picc malpositioned, pulled back 5cm, please rexray\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with malpositioned picc\n REASON FOR THIS EXAMINATION:\n picc malpositioned, pulled back 5cm, please rexray\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Re-evaluate PICC positioning.\n\n COMPARISONS: Chest radiograph at 9:43.\n\n FINDINGS: The right PICC is no longer curled in the SVC. The tip now\n terminates in the upper SVC. Again noted is mild bibasilar atelectasis and\n mild pulmonary edema. There is no pleural effusion or pneumothorax. The\n cardiomediastinal silhouette is unchanged.\n\n IMPRESSION: Right PICC terminates in the upper SVC.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807926, "text": " 6:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with retained metal stent LMSB and RMSB and LMSB stenosis s/p\n Y-stent placement\n REASON FOR THIS EXAMINATION:\n ptx?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lung cancer, status post Y-stent placement.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST, AP: The ET tube lies approximately 5 cm above the carina.\n The bronchial stents are not well visualized. The NG tube is seen coursing in\n the stomach. The left subclavian Port-A-Cath is in unchanged and appropriate\n position within the distal SVC. No pneumothoraces. There has been\n development of increased atelectasis on top of the previously seen right\n upper lobe atelectasis/scarring. The lung fields are otherwise clear. No\n pleural effusions.\n\n IMPRESSION: No pneumothorax.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2151-01-17 00:00:00.000", "description": "Report", "row_id": 1608789, "text": "NPN 1900-0700:\nNeuro: alert, oriented x3, denied any pain or discomfort except for mild throat pain, resolved by itself and minimal discomfort at back, relieved by changing positioning and back rub.\n\nResp: breathing regularly on RA, RR 16-26, SPO2 97-100%, LS CTA.\n\nCV: NSR-ST HR 84-104, BP 100-125/59-85, with 2 PIV lines, FS 131 at bed time covered with insulin per sliding scale and received pm dose of NPH, palpable peripheral pulses.\n\nGI/GU: abdomen soft, BS present, no BM during night, with Foley adequate U/O, eating with good appetite.\n\nInteg: Intact skin, T max 99.7.\n\nSocial: Many family members visited him and sister updated on .\n\nPlan: Continue same tx, possible discharge home today.\n" }, { "category": "Nursing/other", "chartdate": "2151-01-15 00:00:00.000", "description": "Report", "row_id": 1608785, "text": "NPN 7P-7A\nTHIS IS A 34YO MALE WHO PRESENTED TO OSH WITH N/V/D X3 DAYS. HE DOES HAVE PMH OF TYPE 1 DIABETES, HOWEVER, WAS NOT TAKING HIS INSULIN FOR THOSE 3 DAYS. HIS BLOOD GLUCOSE UPON ARRIVAL WAS 1200. HE WAS TRANSFERRED TO EW FOR FURTHER TREATMENT. IN EW HE WAS FOUND TO BE IN RENAL FAILURE AND WAS ALSO POSITIVE FOR COCAINE IN URINE. HE WAS STARTED ON INSULIN GTT AND TRANSFERRED HERE TO MSICU.\n\nNEURO: PT. VERY LETHARGIC AND RESTLESS. ORIENTED X2. UNABLE TO OBTAIN AN ACCURATE HISTORY AS PT. INCONSISTENTLY ANSWERING QUESTIONS ASKED. PUPILS EQUAL AND REACTIVE.HE DID HAVE A HEAD CT IN EW THAT WAS NEGATIVE.\n\nRESP: PT. REMAINS ON ROOM AIR WITH SATS >97%. BREATH SOUNDS CLEAR BILAT. NO SOB OR COUGH NOTED AT THIS TIME.\n\nCV: PT. ST WITH RATE 110'S TO 120'S. EKG OBTAINED TO CONFIRM ST. SBP LOW 100'S TO MID 110'S. + PULSES. NO EDEMA. TMAX 99.3\n\nGI: ABDOMEN SOFT. BS+ PT. ORDERED FOR CLEAR LIQUID DIET AND ADVANCE AS TOLERATED. PT. ASLEEP MOST OF SHIFT AND REFUSING TO EAT AT THIS TIME. NO C/O N/V. LAST BM YESTERDAY AT HOME PER PT.\n\nGU: FOLEY CATH IN PLACE DRAINING CLEAR YELLOW URINE. UO APPEARS TO BE PICKING UP AT THIS TIME. APPROX. 100CC OUT PER HOUR. BUN AND CREAT APPEAR TO BE DECREASING AS WELL.\n\nSKIN: INTACT\n\nACCESS: 3 PIVS ALL PATENT\n\nENDO: PT. REMAINS ON INSULIN GTT. AT THIS TIME HE IS ON 8U/HR. TITRATE AS NEEDED. PT. ON D5 1/2 NS AT THIS TIME FOR 1 LITER. (HUNG AT 0245)\n\nPLAN: CONTINUE WITH CURRENT PLAN OF CARE. MONITOR BLOOD SUGARS Q1H. MONITOR UO CLOSELY AS WELL. AM LABS PENDING. MD'S DID SPEAK WITH PT.'S SISTER WHEN HE ARRIVED. PT. DOES NOT HAVE HCP AT THIS TIME. HE IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2151-01-15 00:00:00.000", "description": "Report", "row_id": 1608786, "text": "ADDENDUM TO NPN 7P-7A\n30MMOL K PHOS AND 3GM CA GLUCONATE HUNG AT 0600. AM LABS DRAWN BEFORE THESE INFUSIONS STARTED.\n" }, { "category": "Nursing/other", "chartdate": "2151-01-16 00:00:00.000", "description": "Report", "row_id": 1608787, "text": "NPN-MICU\nMr to recover from his DKA.\n\nEndo:pt's BS have decreased nicely on IV reg insulin, it has been weaned to 1u/hr and his serum CO2 is back to normal. He has tol more po's like custard and jello, min c/o nausea. He has more of a sore throat, which prevents him from eating too much.\n\nGU:pt's K+ and Phos have been replaced. His NA++ is up to 150 but he is now taking water and c/o being thirsty. His u/o has increased up to 60cc/hr and his BUN/CR are decreasing as well.\n\nGI:as above, pt taking more po's, and he is looking forward to breakfast. He has not had any stool.\n\nCV: he is maintiang BP 100-120's/ 70's, Hr 90-110 SR/ST.\n\nResp:pt on RA with clr lungs and O2 sats of >98%\n\nNeuro:pt is fully particiapting in care, MAE. He c/o not being able t sleep and got .5mg IV ativan with good results.\n\nID:His fever is dropping nicely and WBC ct is 9 (12). ultures are pnd\n\nA/P:Will to follow BS closely and wean Insulin as needed\n Adv diet in am if pt says he is ready, then ?change to NPH and Reg Insulin SQ SS.\n to folow renal function and u/o, allow pt to correct NA++ on own with po water. Replace lytes as needed\n Await cx reslults, IVAB\n\n" }, { "category": "Nursing/other", "chartdate": "2151-01-16 00:00:00.000", "description": "Report", "row_id": 1608788, "text": "NPN 0700-1900\n\nNeuro: A&O X3 by the afternoon, more foggy early am; pleasant, cooperative, denies pain. OOB to chair for most of day; steady gait.\nFamily in to visit all afternoon.\n\nCV: NBP 98-120/61-71; HR 89-101, NS/ST. No peripheral edema, pulses intact.\n\nResp: Regular, unlabored; lungs clear, no cough; O2 sat 98-99%, RR 17-28.\n\nGI/FEN: Abdomen soft, ND, NT, +BS, no stools. Apetite very good, advanced to regular, diabetic diet. 1600 labs Na 148, K 3.2, phos 1.5 -> to receive neutra phos and po K repletion.\n\nGU: Foley intact, draining 60-90cc/hr clear yellow urine. Taking fluids well. BUN/Cr 25/13.\n\nEndo: BS 96-259, insulin gtt ranged from 2-4units/hr, presently at 2/hr and to be d/c'd after he eats dinner. To start SSI and fixed doses at breakfast and bedtime; given tonight's dose before dinner recs.\n\nID: Afebrile; BC results showed +GPC in bottles, ?contamination. Flagy d/c'd and BC drawn X1.\n\nPlan: Monitor BS and follow SSI; monitor fluid/electrolytes, replete prn; encourage OOB; ? d/c tomorrow if stable.\n" }, { "category": "ECG", "chartdate": "2151-01-15 00:00:00.000", "description": "Report", "row_id": 169181, "text": "Sinus tachycardia. Since the previous tracing of the rate has slowed\nand ST-T wave abnormalities are improved.\n\n" }, { "category": "ECG", "chartdate": "2151-01-15 00:00:00.000", "description": "Report", "row_id": 169182, "text": "Baseline artifact. Probable sinus tachycardia. Possible inferior ST-T wave\nchanges. If clinically indicated, a repeat tracing may be beneficial. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2151-01-14 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 940988, "text": " 10:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD PAIN, N/V, NOW DKA.\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with abd pain, N/V, then stopped insulin, now in DKA\n REASON FOR THIS EXAMINATION:\n eval: appy (IV CONTRAST ONLY, PLEASE)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:22 PM\n Limited study but normal appendix, no inflammatory changes, no free fluid.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old male with abdominal pain, nausea and vomiting,\n stopped insulin, now in DKA.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained\n without the administration of intravenous contrast or oral contrast\n . Oral contrast was not tolerated by the patient, and IV contrast was\n not administered due to elevated creatinine.\n\n Multiplanar reformation images are reconstructed.\n\n No comparison.\n\n FINDINGS: The evaluation of the major abdominal organs and vessels are\n limited due to lack of intravenous and oral contrast, and also due to artifact\n from the arms. There is no evidence of free air, free fluid, or fluid\n collection in the abdomen. Appendix measures 3 mm with air and is normal\n without evidence of inflammatory changes. Liver has focal fatty infiltration\n in the anterior segment of S4. No other focal liver lesion is demonstrated on\n non-contrast study. Spleen, pancreas, gallbladder, adrenal glands and\n kidneys, the visualized portion of large and small intestines are within\n normal limits.\n\n PELVIS: The visualized portion of large and small intestines are within\n normal limits. There is no ascites or lymphadenopathy.\n\n There is patchy opacity in the left lower lobe, which can be due to aspiration\n or atelectasis.\n\n There is no suspicious lytic or blastic lesion in skeletal structures.\n\n IMPRESSION: Limited study without intravenous or oral contrast. Normal\n appendix. No evidence of free fluid or free air in the abdomen. No acute\n inflammatory process.\n\n The finding was discussed with Dr. in person at the completion of\n the study.\n\n (Over)\n\n 10:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD PAIN, N/V, NOW DKA.\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2151-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 940977, "text": " 8:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: DKA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with DKA, tx'd from OSH\n REASON FOR THIS EXAMINATION:\n eval: edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old male with transferred from an outside hospital.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: No intra- or extra-axial hemorrhage is identified. There is no\n mass effect or shift of normally midline structures. The density of the brain\n parenchyma and the -white differentiation is within normal limits. There\n is no ventriculomegaly. The visualized paranasal sinuses and mastoid air\n cells do not demonstrate any air-fluid levels. There is mild mucosal\n thickening of the left maxillary sinus. Soft tissue structures appear\n unremarkable.\n\n IMPRESSION: No evidence of intracranial hemorrhage or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 940974, "text": " 8:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval: PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with DKA\n REASON FOR THIS EXAMINATION:\n eval: PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old male with DKA.\n\n COMPARISONS: None.\n\n AP UPRIGHT CHEST: Heart size, mediastinal, and hilar contours are normal.\n The lungs are clear. No pleural effusions or pneumothoraces. No focal\n pulmonary parenchymal consolidation is identified. The pulmonary vasculature\n is not congested.\n\n IMPRESSION: No evidence of pneumonia or CHF.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2105-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 770009, "text": " 9:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: gallstone pancreatitis, failure to wean, please assess, for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 yo man with gallstone pancreatitis, failure to wean.\n REASON FOR THIS EXAMINATION:\n gallstone pancreatitis, failure to wean, please assess\n for CHF.\n ______________________________________________________________________________\n FINAL REPORT\n Compared to two days earlier.\n\n CLINICAL INDICATION: Failure to wean from ventilator.\n\n An endotracheal tube, left PICC line and permanent pacemaker remain in place.\n The distal aspect of the pacing lead cannot be assessed due to exclusion of\n the lower heart from the radiograph. Cardiac and mediastinal contours are\n stable allowing for differences in technique and allowing for respiratory\n motion. There is persistent vascular engorgement and perihilar haziness.\n Bilateral pleural effusions and left retrocardiac opacity are unchanged.\n\n IMPRESSION: Allowing for differences in technique, there has been no\n significant interval change other than removal of a right internal jugular\n vascular catheter.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769901, "text": " 10:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt with acute drop in o2 sat\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with biliary sepsis\n REASON FOR THIS EXAMINATION:\n Pt with acute drop in o2 sat\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilary sepsis with respiratory distress and drop in oxygen\n saturation.\n\n ET tube is 4 cm above carina. Right jugular CV line is in proximal SVC. NG\n tube present with distal end not included on film but probably extends below\n diaphragm. Left PICC line is in SVC. No pneumothorax. There is cardiomegaly\n with upper zone redistribution, probable interstitial edema and bilateral\n pleural effusions. The left hemidiaphragm is obscured and\n atelectasis/consolidation in the left lower lobe may be present. In addition,\n atelectasis is likely present at the right lung base.\n\n IMPRESSION: CHF with interstitial pulmonary edema, pleural effusions and\n bibasilar atelectases. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 769285, "text": " 7:25 PM\n CHEST (PA & LAT) Clip # \n Reason: increased hypoxia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with biliary sepsis\n REASON FOR THIS EXAMINATION:\n increased hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS PA & LATERAL:\n\n HISTORY: Biliary sepsis and hypoxia with respiratory distress.\n\n There is cardiomegaly with tortuosity of the aorta. There is upper zone\n redistribution and bilateral pleural effusions consistent with CHF. A right\n sided dual chamber pacemaker is present with atrial and ventricular leads in\n situ in good location. There is flattening of the diaphragms consistent with\n COPD. The left hemidiaphragm is elevated and there is atelectasis and possible\n area of consolidation in the left lower lobe.\n\n IMPRESSION: Cardiomegaly with CHF and bilateral pleural effusions. Atelectasis\n and probable associated consolidation in the left lower lobe with elevated\n left hemidiaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769365, "text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for the placement of ett\n ______________________________________________________________________________\n MEDICAL CONDITION:\n INCREASING HYPOXIA, s/p intubation\n REASON FOR THIS EXAMINATION:\n please evaluate for the placement of ett\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia and intubation. To evaluate ET tube.\n\n ET tube is 5 cm above carina. No pneumothorax. There is cardiomegaly and\n tortuosity of the thoracic aorta. Bibasilar opacities consistent with\n bilateral pleural effusions and bibasilar atelectasis, as previously\n demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769539, "text": " 8:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 82 yo man with gallstone pancreatitis/cholangitis with pneum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 yo man with above\n REASON FOR THIS EXAMINATION:\n 82 yo man with gallstone pancreatitis/cholangitis with pneumonia. eval lung\n fields and ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gallstone pancreatitis with pneumonia check endotracheal tube\n position.\n\n Because of the patient's size and the films are always taken portably it is\n difficult to obtain enough penetration for adequate penetration of the\n mediastinal shadows. The tip of the endotracheal tube appears to end at the\n thoracic inlet approximately 7 cm above the carinal angle. The left\n hemidiaphragm is obliterated suggesting the continued presence of a left lower\n lobe infiltrate. Gross failure is probably not present. There is a dual\n chamber pacemaker with the tips in the right atrium and right ventricle.\n\n IMPRESSION: Endotracheal tube at thoracic inlet with continued opacification\n of left lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769542, "text": " 10:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 82 yo with pna, intubated. eval ett position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 yo man with above\n REASON FOR THIS EXAMINATION:\n 82 yo with pna, intubated. eval ett position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia. Recent intubation. Evaluate ET tube position.\n\n AP CHEST: The study is inadequate to evaluate ET tube position due to a\n combination of patient motion and body habitus.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-20 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 769841, "text": " 8:23 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: 82 yo male with cholangitis/pancreatitis increasing bilis. P\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with cholangitis/pancreatitis\n REASON FOR THIS EXAMINATION:\n 82 yo male with cholangitis/pancreatitis increasing bilis. Please assess\n biliary tree, pancrease. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cholangitis and pancreatitis. Evaluate biliary tree.\n\n LIMITED ABD US: The common bile duct is 0.6 cm. There is no intrahepatic\n biliary dilatation. The gallbladder is collapsed and contains multiple\n stones. There is no pericholecystic fluid or gallbladder wall edema. The\n liver has a homogeneous echo texture. The main portal vein is patent with\n hepatopetal flow. No definite flow is identified in the left portal vein. No\n ascites.\n\n IMPRESSION:\n\n 1. No biliary dilatation.\n 2. No flow identified within the left portal vein. While this may be due to\n technical factors, repeat examination is recommended if further evaluation is\n indicated.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2105-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769567, "text": " 1:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evlaute for the placement of the tlc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 yo man with right ij change.\n REASON FOR THIS EXAMINATION:\n please evlaute for the placement of the tlc\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ line change.\n\n A faintly visualized right IJ line is present. No definite pneumothorax is\n seen. The lower aspect of both the lungs and portions of the heart are\n excluded from the chest X-ray. The heart appears to be enlarged and the\n overall appearance of the chest does not appear to have changed significantly\n since the earlier chest X-ray at 8:30 am on . An NGT and ETT are\n noted. The ETT terminates at the thoracic inlet.\n\n IMPRESSION: There is no apparent pneumothorax following line insertion.\n Otherwise, the appearance of the chest has not changed significantly since\n 8:36 am on .\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-12 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 769257, "text": " 1:29 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with abd pain\n\n please perform in radiology suite.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Abdominal pain. Evaluate for obstruction.\n\n Distribution of bowel gas is unremarkable and there is no evidence for\n intestinal obstruction. No diagnostic abnormalities on this film.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769305, "text": " 6:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INCREASING HYPOXIA\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n INCREASING HYPOXIA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing hypoxia.\n\n COMPARISON STUDY: \n\n CHEST SINGLE VIEW: The heart is enlarged. The left costophrenic angle is\n excluded on this film. There is persistent basilar opacification related to a\n small to moderate left-sided pleural effusion with associated atelectasis.\n There is a small right-sided pleural effusion with some associated basilar\n atelectasis. Both have not significantly changed in the interval. There is\n no significant pulmonary vascular engorgement.\n\n IMPRESSION: Cardiomegaly without significant CHF. Stable bilateral pleural\n effusions left greater than right with associated basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-20 00:00:00.000", "description": "CVL/PICC", "row_id": 769863, "text": " 12:56 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: 82 male pancreatitis cholangitis in ICU needs IV access. Ple\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with pancreatitis/cholangitis.\n REASON FOR THIS EXAMINATION:\n 82 male pancreatitis cholangitis in ICU needs IV access. Please place PICC.\n Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: 82 y/o man with pancreatitis and cholangitis. Patient requires\n longterm IV antibiotics and TPN.\n\n PROCEDURE/TECHNIQUE: The procedure was performed by Dr. and Dr.\n , with Dr. , Attending Radiologist, being present and supervising\n the procedure. The left upper arm was prepped and draped in the usual sterile\n fashion. Since no suitable superficial veins were visible, ultrasound was used\n for localization of a suitable vein. The basilic vein was patent and\n compressible. After local anesthesia with 2 cc 1% Lidocaine the basilic vein\n was entered under ultrasonographic guidance with a 21 gauge needle. A 0.018\n guide wire was advanced under fluoroscopy into the superior vena cava. Based\n on the markers on the guide wire it was determined the length of 53 cm would\n be suitable. The PICC line was trimmed to length and advanced over a 4 FR\n introducer sheath under fluoroscopy guidance into the superior vena cava. The\n sheath was removed The catheter was flushed. A final chest X-ray was obtained\n documenting the tip to be at the SVC/right atrial junction. The line is ready\n for use.\n\n A statlock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of a 53 cm full length 4 FR dual lumen PICC\n line with tip in SVC, ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-13 00:00:00.000", "description": "P ERCP S&I (74330) PORT", "row_id": 769373, "text": " 5:50 PM\n ERCP S&I () PORT Clip # \n Reason: cholangitis and biliary pancreatitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old critically ill man in ICU with biliary pancreatitis and cholangitis\n and multiple medical comorbidities.\n REASON FOR THIS EXAMINATION:\n cholangitis and biliary pancreatitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Cholangitis and biliary pancreatitis.\n\n ERCP: Selected spot images from ERCP performed by Dr. are provided\n for interpretation. The provided images are very low in contrast and the\n biliary stone visualized during the procedure is not clearly evident. The\n common duct is minimally dilated. Stone extraction was performed.\n\n IMPRESSION: Successful stone extraction.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769505, "text": " 9:42 AM\n CHEST (PORTABLE AP); ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: 82 yo man with pna, intubated.eval lungs, 82 yo man with abd\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 yo man with above\n REASON FOR THIS EXAMINATION:\n 82 yo man with pna, intubated.eval lungs\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL HISTORY: Pneumonia. Intubated.\n\n Chest. Because of patient's size the film is underpenetrated. The position\n of the endotracheal tube is difficult to establish but probably lies in the\n region of the thoracic inlet. The left hemidiaphragm is obscured suggesting a\n left lower lobe infiltrate. Dual-chamber pacemaker is seen and the heart\n remains enlarged.\n\n IMPRESSION: Left lower lobe opacification consistent with pneumonia.\n\n" }, { "category": "Echo", "chartdate": "2105-08-14 00:00:00.000", "description": "Report", "row_id": 72647, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 122/70\nStatus: Inpatient\nDate/Time: at 10:42\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is markedly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. There is moderate global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. Right ventricular\nsystolic function appears depressed.\n\nAORTA: The aortic root is moderately dilated. There are focal calcifications\nin the aortic root. The ascending aorta is moderately dilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. There is mild thickening of the mitral valve\nchordae. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\n[2+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views. Based on AHA endocarditis\nprophylaxis recommendations, the echo findings indicate a moderate risk\n(prophylaxis recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data. The\nechocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left and right atrium are dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and moderate global\nhypokinesis. The right ventricular cavity is dilated with free wall\nhypokinesis. The aortic root and ascending aorta are moderately dilated. The\naortic valve leaflets (3) are mildly thickened but not stenotic. No aortic\nregurgitation is seen. The mitral valve leaflets and supporting structures 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\nIMPRESSION: Symmetric left ventricular hypertrophy with global hypokinesis.\nRight ventricular cavity enlargement with free wall hypokinesis. Pulmonary\nartery systolic hypertension.\nThe right sided findings are c/w a primary pulmonary process (pulmonary\nembolism, exacerbation of COPD, pneumonia, etc.)\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": "ECG", "chartdate": "2105-08-12 00:00:00.000", "description": "Report", "row_id": 172933, "text": "Atrial paced but probable not capture\nVentricular capture\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2105-08-21 00:00:00.000", "description": "Report", "row_id": 1266256, "text": "7P-7A NPN\nNEURO: PT AROUSES INCONSISTENTLY ONLY TO PAINFUL STIMULI. DOES NOT FOLLOW COMMANDS, NO SPONTANEOUS MOVEMENT OF EXT NOTED. FACIAL GRIMACING PRESENT WITH PAIN AT TIMES.\n\nRESP: PT WITH COPIOUS BLOOD TINGED SECRETIONS VIA ETT. SPO2 DOWN TO 75% EARLY IN SHIFT, RECOVERED WITH INC PEEP AND VIGOROUS SUCTIONING. MD AWARE. CURRENT SETTINGS: AC 16 TV 600 40% +10. RESP RATE 17-34. RESPS INCREASE WITH STIMULATION AND RETURN TO BASELINE WHEN ALONE IN ROOM. LUNGS COARSE TO DIMINISHED IN BASES. DYSYNCHRONOUS WITH VENT AT TIMES, USE OF ABD ACCESORY MUSCLES NOTED.\n\nCV: AV PACED 55, NO ECTOPY. BP 150'S SYSTOLIC THROUGHOUT SHIFT, INC WHEN AGITATED. ALINE WAVEFORM UNDERDAMPED AT TIMES ? ACCURACY. A LINE DSG CHANGED AND CATHETER IS NOTED TO HAVE A KINK. GEN EDEMA +.\n\nGI/GU: TF INC TO 50, NO RESIDUALS, BS +. NO STOOLS. FOLEY PATENT DRAINING MED YELLOW URINE WITH SEDIMENT. NGT TO R PLACEMENT VERIFIED X3 WITH AIRBOLUS.\n\nIV: L BRACHIAL PICC, R TLIJ INTACT\n\nINTEG: PERI AREA/ABD FOLDS REDDENED/EXCORIATED IN PLACES, NYSTATIN POWDER APPLIED. COMPLETE BED BATH GIVEN, NO BREAKDOWN NOTED ON BACK OR COCCYX. ORAL LESIONS WITH ZOVIRAX CREAM APPLIES.\n\nPLAN: CONT WEAN TODAY, REMAINS OFF ALL SEDATION, HEALTH CARE PROXY ISSUES WITH FAMILY, CONT SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-21 00:00:00.000", "description": "Report", "row_id": 1266257, "text": "MICU/SICU NPN HD #8\nS/O:\n\nNeuro: remains responsive to painful stimuli only, no spontaneous movement of extremities noted\n\nResp: tolerating PSV 15+10 with FiO2 0.40 all day, LS diminished all fields, sucioned q3h for thick tan secretions\n\nCV: Paced rhythm at 55, no VEA noted, please see flowsheet for details\n\nSkin: C/W/D/I. 3+ global edema, herpetic rash on lips\n\nGi/GU: abd obese, soft, NT/ND, BS present, tolerating Promote with fiber at goal rate of 75cc/h. Foley patent for clear yellow urine in adequate amts.\n\nLines: right radial art line, DL PICC in left AC\n\nID: afebrile, continues on Levo/Zosyn\n\nDisp: DNR\n\nA:\n\naltered nutrition, LBR r/t poor caloric intake > 7 days\nrisk for infection r/t invasive lines\n\nP:\n\ncontinue to monitor hemodynamic stability, continue TF as ordered, continue abx as reccomended\n" }, { "category": "Nursing/other", "chartdate": "2105-08-22 00:00:00.000", "description": "Report", "row_id": 1266258, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt vented on settigns of PSV 10cm Peep of 10cm, pt RR 18-20 triggering the vent w;ith TV 600cc however he was shallow breaths, not triggering vent for a RR 30's ABG done, placed back on A/C 18x600cc FIO2 40% Peep of 10cm. still not settling increased TV to 800cc with good results. suctioned for thick yellow to tan sputum requiring NS instill.\n\n Cardiac: HR 55 A-V paced, BP 140-180/70's urine ouptu continues to be good. wt down to 132.6 KG less edema in the legs, still present in the arms.\n\n GI: on Tf of Nepro at 40cc/hr with low residuals. +BS, +flatus,\n\n Line access; PICC in the left arm.\n\n skin: rash in groin area treated with nyastin powder.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-08-13 00:00:00.000", "description": "Report", "row_id": 1266238, "text": "NPN addendum\n\nPt is to have 3liters max today,2liters in already, give FFP slowly aand hold IVF during infusion.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-14 00:00:00.000", "description": "Report", "row_id": 1266239, "text": "Respiratory Care\nPt.remains intubated and ventilated. Multiple vent changes made overnight to optimize airway pressures and oxygenation. He desaturates and becomes agitated when awake at all. Currently, he appears comfortable and well sedated. Settings are a/c 600 x 16 60% 10 of peep with improved abgs. Suctioning thick geenish plugs.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-14 00:00:00.000", "description": "Report", "row_id": 1266240, "text": "NPN (NOC): PT REMAINS INTUBATED. CURRENT VENT SETTINGS: A/C 16X600X60% + 10 OF PEEP. PROPAFOL CHANGED TO FENTYNL AND ATIVAN DRIPS. PT IS ADEQUATELY SEDATED MOST OF THE TIME BUT WHEN HE IS AWOKEN FOR PROCEDURES, HE BECOMES QUITE AGITATED REQ FENTYNL/ATIVAN BOLUSES. BS'S COURSE. SX'D SEV TIMES FOR SM TO LG AMTS OF THICK TAN SECRETIONS (SPEC SENT ALONG W/ BLOOD & URINE CX'S.) AFEBRILE. RENAL RANGE DOPA BEGUN W/ IMMEDITATE IMPROVMENT IN UO OF UP TO 120 CC'S/HR. IVF IS AT KVO, I&O'S SINCE MN ARE RUNNING -. TEAM THINKS THAT HE IS OVERLOADED AND IN CHF. HAS BEEN HEMODYNAMICALLY STABLE. IS NPO, NGT WAS ON LIS, BUT I SAW A SM AMT OF BLOOD COMING UP AND TUBE IS NOW CLAMPED. RECIEVED AN ADDITIONAL 2 BAGS FFP LAST NOC AND TOL WELL. AM COAGS PND.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-14 00:00:00.000", "description": "Report", "row_id": 1266241, "text": "MICU/SICU NPN HD #2\nS/O:\n\nNeuro: remiains sedated on fentanyl and Ativan, no spontaneous movement of extremitites\n\nResp: remains intubated on AC 16x600x0.60+15, Last ABG 7.33/95/48/26/-1, LS coarse in upper lobes, fine rales at left base, right base dim, rare exp wheezes\n\nCV: pt remains hypotensive, minimally responsive to fluid bolus, remains on dopamine at 1.5 mcg/kg/min, please see flowsheet for data\n\nSkin: C/W/D/I, global trace edema, pt placed on BariAir rotating bed\n\nGI/GU: abd firm and distended, tender to touch, NGT clamped, Foley patent for dark yellow urine with sediment in adequate amts\n\nLines: right radial art line, right femoral TLCL, #22 angio left wrist, #22 angio right forearm\n\nID: afebrile, continues on Unasyn, and will start Levaquin\n\nSoc: children in to visit and speak with team, Full code\n\nA:\n\nhigh risk for infection r/t invasive lines\nrisk for altered nutrition r/t poor caloric intake (NPO)\nhigh risk for injury r/t sedation, invasive lines, ETT\n\nP:\n\ncontinue to monitor hemodynamic stability, continue abx as ordered, nutrition c/s to evaluate need for parenteral nutrition, contine ot wean sedation as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2105-08-15 00:00:00.000", "description": "Report", "row_id": 1266242, "text": "NPN (NOC): PT REMAINS INTUBATED. CURRENT VENT SETTINGS: A/C 16X600X50% + 10 OF PEEP. SATS BETTER LAST NOC, TO MID 90'S. AM ABG PND. WELL SEDATED ON CURRENT LEVELS OF FENTYNL/ATIVAN, ONLY NEEDED (2) 1 MG BOLUSES OF ATIVAN FOR BITING ON TUBE. REMAINS HEMODYNAMICALLY STABLE ON 1.5 MCG'S OF DOPA. UO HAS BEEN 30- 40 CC'S/HR WHICH IS GOAL PER HO.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-20 00:00:00.000", "description": "Report", "row_id": 1266254, "text": "7P-7A END OF SHIFT NOTE\nDNR\nUNIVERSAL/CONTACT PRECAUTIONS\n\nneuro: pt sedated on ativan gtt at 0.5mg/hr and fentanyl at 30mcg/hr. these gtts have been titrated down over coarse of shift. pt will slightly open eyes to much verbal stimuli and touch. will not follow any commands. does withdraw and slight localize w/ painful stimuli to all extremities. does grimace also. perla at 3mm currently.\n\nresp: intubated w/ 8.0 ett 22cm at lip. ac 18/tv 600/peep 7.5/fio2 .4. breathing along w/ vent at 18. no overbreathing seen. sats 93-97%. lungs sounds very decreased throughout. ett sx small amt yellowish to occas blood tinged secretions. moderate amt thick whitish oral secretions. good cough w/ sx.\n\ncardiac: av paced at 55. lt a-line w/ good waveform w/ sbp mid 90s - 140s. correlates fairly close w/ nibp cuff. edema noted throughout all extremities and scrotum. pedal pulses dopplered. pt afebrile all shift. cvp 11-15. rij triple lumen intact. bil sequential stockings on.\n\ngu/gi: abd obese and slightly distended w/ hypo bowel sounds. rectal tube dc'd as no stool over 24 hrs. foley draining 55-100cc/hr yellow urine w/ sediment. rt sump to lis draining moderate amt bilous drainage.\n\nskin: bil groin, under scrotum, lower abd folds and perianal area red, antifungal powder applied. yellow apprearance to skin (esp face and back/abd) otherwise intact. possible herpes lesions to lower lip, apply acyclovir q2hr.\n\nplan: u.s. for possible picc placement otherwise plan to go to interventional radiology for placement. start tpn today?\n" }, { "category": "Nursing/other", "chartdate": "2105-08-20 00:00:00.000", "description": "Report", "row_id": 1266255, "text": "MICU/SICU NPN HD #7\nS/O:\n\nNeuro: pt remians unarousable after fentanyl/Ativan d/c'd, no spontaneous movement of extremities noted, no sz activity noted\n\nResp: remians intubated, switched to PSV 15+5 with FiO2 0.40 this AM, pt tolerating fairly well, last ABG 7.28/75/43/21/-6. Suctioned q3-4h for small amts thick tan secretions.\n\nCV: please see flowsheet for data\n\nSkin: C/W/D/I, + global edema. Pressure ulcer from ETT on lower lip, treating with Acyclovir oint.\n\nGI/GU: abd obese, soft, faint BS present, NGT clamped and TF initiated, currently Nepro @ 20cc/h, check residual q4h and advance to goal rate of 60cc/h. Foley patent for dark yellow urine in adequate amts.\n\nLines: left IJ TCLC, left radial art line, DL PICC placed today in left basilic vein under fluro\n\nID: afebrile continues on Zosyn/Levaquin\n\nSoc: daughter in to visit, met with to discuss progress/plan. DNR.\n\nA:\n\nhigh risk for infection r/t invasive lines\naltered nutrition, LBR r/t poor caloric intake > 7 days\n\n\nP:\n\ncontinue to monitor hemodynamic stability, continue TF as ordered and advance to goal rate of 60cc/h, initiate TPN this PM, continue abx as ordered, pan culture if pt spikes\n" }, { "category": "Nursing/other", "chartdate": "2105-08-13 00:00:00.000", "description": "Report", "row_id": 1266236, "text": "Respiratory Care Note:\n Patient admitted to MICU on 50% venti mask. SAO2=low 90's. BS with rales and rhonchi scattered t/o. Cough loose and non-productive. Respirations 28 and slightly labored. Albuterol and atrovent med neb given via mask. ABG sent. BS with possible increased aeration post tx.\nHe complains of being tired. Remains on 50% VM /SAO2=93%, RR=22, HR=55 (paced).Patient has edematous ankles and feet. His skin is warm and dry and pink. Plan to follow as needed. Ambu bag and mask at head of bed.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-13 00:00:00.000", "description": "Report", "row_id": 1266237, "text": "NPN 0700- see careview for details\nADMIT NOTE\n\nAdmitted to MICU from 12 GI after cancelled ERCP this AM due to poor resp compensation.Family in and spoke w/team ,agreed to allow for intubation and ERCP.Recieved pt awake and alert, but confused about place and why he was in hosp.Pt was tachypeniec and had rales in all lung .UO was 10-20 cc/hr .Pt was intubated at bedside,sedated by anesthesia, required further sedation w/versed and fentynal while on vent.R fem TLC was placed by HO. ERCP at bedside , pt recieved 1mg Vit K prior to procedure, and 2 units FFP during procedure. Evacuated large stone and puss in bile duct.\n\nNUERO: sedated w/ profofal IV.\n\nRESP:A/C 16X450 7.5 PEEP 100 fio2.Lungs coarse throughout sats 90-97%.\n\nC/V: A/V paced episodes of hypotension corrected w/fluid boluses.Recieved Dopamine @ 2 mcg during procedure.Now off.Maintaining BP in 90-100's.\n\nF/E/N/: NPO , IVF @ 75cc/hr.UO 10-15 cc/hr HO aware.NGT to LCS.\n\nPLAN: wean prof ,use fentynal and versed GTT. cont vent at present settings.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-18 00:00:00.000", "description": "Report", "row_id": 1266251, "text": "MICU NPN:\nNEURO: PERL 2mm and brisk. Weaned ativan to 4mg/hr and fentanyl now at 125mcg/hr. Biting tube occasionally and moving head slightly. Opens eyes to painful stimuli.\nCV: Afeb. HR 55 AV paced, no ectopy. Dopamine weaned off with SBP 80s-100s. BP 80/40 at 1545 and 500cc NS bolus given with some effect. Continue to monitor BP closely. CVP 10-14. Skin warm and dry with weak but palpable pulses.\nRESP: Vent AC 600x18 FiO2 50% Peep weaned to 10. Lungs coarse and diminished to bases. Sx'd for small amts of thick yellow secretions. RR18- not breathing over vent.\nGI/GU: Abd. distended and slightly firm. Hypoactive bowel sounds. Rectal tube placed with no gas or BM noted. NGT to ILWS with bilious drainage ~300cc q6hrs. Foley draining cloudy yellow urine >30cc/hr.\nSKIN: Mouth and nose with ulcers- put on contact precautions for ?herpes zoster. No lesions suitable for culture at this time. On rotating specialty air mattress. Pneumoboots still unavailable at this time for DVT prophylaxis. R IJ and R A-line intact. Plan to re-wire R IJ for TPN port in am.\nSOCIAL: Daughter into visit and updated by MDs on pt's condition and plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-19 00:00:00.000", "description": "Report", "row_id": 1266252, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt remains intubated on vent settings of A/C600x18 FIO2 50% PEEP at 7.5 cm suctioned q3-4 hr for thick yellow to sl green sputum. BS coarse to diminished at the bases. No changes in the vent during the night. Weaned sedation Ativan at 2mg/hr and fentanyl at 75mcg/hr by morning pt opening eyes spontaneously but not following commands.\n\n Cardiac: Hr 56 A-V paced, BP range 88-120/60-70's lowest when pt in rotation mod with left side down. stopped rotation and BP back up without intervention. CVP ranged 13-15.\n\n GI: oral gastric tube in place on LIS with output averaging 200-300cc per shift. abd soft, hypo active BS no stool\n" }, { "category": "Nursing/other", "chartdate": "2105-08-19 00:00:00.000", "description": "Report", "row_id": 1266253, "text": "MICU NPN:\nNEURO: Weaned ativan to 1mg/hr and fentanyl to 50mcg/hr. PERL. Grimaces with pain. Opens eyes slightly with turning. No following commands. No spontaneous movement noted.\nCV: Afeb. HR 55-60 AV paced. BP 90-120s/40-50s via A-line. Skin warm and slightly moist with dopplerable pedal pulses. Pneumoboots finally received today and applied.\nRESP: Vent AC 600x18 FiO2 40% +7.5 peep with adequate ABG. O2 sat 90-95%. Sx'd for thick pale yellow secretions in moderate amts with moderate amts of oral secretions noted. Lungs coarse and diminished at bases. Not overbreathing vent rate of 18.\nGI/GU: Abd. distended and soft with very hypoactive bowel tones. NGT to ILWS with bilious drainage (300cc in last 12hrs). Rectal tube in place with no BM. To guiac stool. Foley draining yellow urine with sediment >30cc/hr. IV acyclovir d/c'd due to worsening renal function.\nSKIN: Skin intact. Mouth with ulcers and acyclovir cream to be applied q2hrs. On rotating air mattress. Coccyx intact- no breakdown noted. Lines intact.\nSOCIAL: Daughter into visit and asking appropriate questions.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-24 00:00:00.000", "description": "Report", "row_id": 1266262, "text": "MICU-NPN\n\nNEURO: Pt. responds to verbal stimuli, slightly opens eyes. Does not follow commands.\nCV: Tmax: 100.8po, ABP 95-120's/42-49, no ectopy noted. HR 55 av paced, with occasional own heart beat noted. Extremities very edematous, +pp by doppler.\nRESP: no vent changes made, see carevue for data. Suctioned for small amt thick, white/yellow sputum. LS diminished.\nGI: abdomen softly distended, +BS, TF infusing @ goal with no aspirates. stool x1 over noc, Heme neg.\nGU: Foley drng adeq. amt's of cloudy, yellow urine. BUN/CREAT remain elevated.\nID: Continues on Zosyn and Levo.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-24 00:00:00.000", "description": "Report", "row_id": 1266263, "text": "MICU/SICU NPN HD #12\nPt is DNR/CMO\n\nAfter lenghty discussion with Mr. children regarding his wishes not to be rescusitated/intubated or have his life prolonged on life support, it was decided that in light of his lack of progress and the likelihood of further complications that the management of his care be modified to comfort measures only. At 1700 a morphine gtt was initiated, and as discussed with pt's children when pt appears reasonably comfortable he will be extubated.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-25 00:00:00.000", "description": "Report", "row_id": 1266264, "text": "S/MICU Nursing Note\n Pt's morphine increased as his eyes were open, vent settings were 20PSV/PEEP at 5cm decreased to 5PSV/PEEP 5cm waited an hour and monitored RR and extubated at 10pm with daughter and son at bedside. placed on nasal cannula, IV morphine at 18mg/hr. pt comfort measures, family at bedside. Pt died at 2:30 am. at the bedside. Pronounced by Dr. \n" }, { "category": "Nursing/other", "chartdate": "2105-08-17 00:00:00.000", "description": "Report", "row_id": 1266247, "text": "NPN 7P-7A\nNEURO: Pt. conts to need increase sedation due to agitation, biting tube, ativan is now at 5mg/hr, fentanyl is at 150mcg/hr, pt. seems better sedated with this, is not overbreathing vent. Does respond to any stimuli, opens eyes spont.\n\nRESP: No vent changes overnoc, continues on a/c 650x18, fio2 50%, peep 15, am abg 7.40/35/89/-. SX. for sm-mod. amts of thick yellow sputum.\n\nCV: Remains dopa dependent, dopamine is at 2mcg/kg/min, bp 100's/ 50's, a-line is positional at times, bp drops to low 80's at times. HR 55-58 a-v paced.\n\nGI: NGT to lis, draining bilious material 300cc over noc. ABD. remains softly distended, hypoactive bs.\n\nGU: U/O 50-100cc/hr, yellow clear .\n\nSocial: Family meeting yesterday, pt. was made a DNR, daughter could not make any further decision about comfort measures due to she is waiting for pt's brother to come back from vacation and he is health care proxy.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-17 00:00:00.000", "description": "Report", "row_id": 1266248, "text": "Respiratory Care Note:\n Patient weaned to tidal volume of 600 and now PEEP decreased to 12.5. MAP=17.4 and pip/plateau = 30.6/25.4. Still suctioned for tenacious yellow-tannish sputum. ET tube resecured several times today by RN at app 23 cm lip. Pt tongues tube out.BS = bilat,diminished but present t/o to bases. He remains sedated, appears comfortable.Remains on dopamine, ativan and fentanyl and received combivent MDI Q4 and flovent this am.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-08-17 00:00:00.000", "description": "Report", "row_id": 1266249, "text": " 4 ICU NURSING PROGRESS NOTE:\n Cardiac: Remains on dopa 2.0mic/kg/min..attempted to decrease but dropped BP to 80's/. BP range 100-120/50-60. HR 55 AV paced. Has had good u/o..is 1200cc neg. so far today..\n GI: Abdomen firm distended..less so than previous days...LIS..out 700cc green ob- bile\n Respiratory: Intubated and vented..decreased TV with good abgs..decreased peep..maintaining sats high 90's. Moderate amts tan/yellow secretions. Not overbreathing vent.\n Sedation: Requireing occassional bolus of fentanyl..to keep comfortable for procedures..adl..\n Skin: Noted area of breakdown on left corner of mouth..under nose and on r side of nose. HO aware..??herpes..started on acyclovir.\n Social/family coping: Daughter in...aware of poor prognosis..spoke with resident\n" }, { "category": "Nursing/other", "chartdate": "2105-08-18 00:00:00.000", "description": "Report", "row_id": 1266250, "text": "NPN (NOC): REMAINS INTUBATED. VENT SETTINGS UNCHANGED OVERNOC. AM ABG PND. PT APPEARS COMFORTABLE ON 5-ATIVAN/150-FENTYNL BY CI, ONLY NEEDED ONE 2MG ATIVAN BOLUS FOR BITING ON TUBE. UO IS MORE THAN ADEQUATE. DOPA CONT AT 2 MCG'S (DID NOT TOL WEAN YESTERDAY AND SBP'S ON THE LOW SIDE OVERNOC.)\n" }, { "category": "Nursing/other", "chartdate": "2105-08-22 00:00:00.000", "description": "Report", "row_id": 1266259, "text": "pmicu nursing progress note\nresp: present vent settings of ac 40% tv 800 x 14 vented breathes (with 2-4 spont breathes) and 7.5 peep----abg of 79 38 7.38 and an o2 sat of 94-95%. pp are also 29. earlier on 16 vented breathes and 7.5 peep the abg was 109 39 7.37. lung sounds deminished. suctioned, after lavaging with 20-30cc of normal saline, for a moderate amt of thick light yellow sputum. off all sedation.\n\ncardiac: bp 130-180/50-60 with a pulse of 55 avp---interm will have own heart beat. with any physical stimulation pt's bp becomes elevated to 180/60, but resolves without intervention when pt left alone. k+ was 4.9. extremities are still edematous, especially the right and left hands. weak pedal pulses.\n\nid: temp at 8a was 99.4po, and at 12p 99.8 po and at 3p 100.8 rectally and at 4p 99.7po. wbc was 12.5. on zosyn and levo. sputum sent for culture and gram stain.\n\ngi: abdomen distended/slightly soft. + bowel sounds. passed a moderate amt of brown soft, ob neg, stool. tube feeds of promote with fiber infusing at goal at 75cc/hr via an ng tube (no aspirates obtained). receiving free water boluses of 250cc q 6 hours.\n\ngu: foley in place. bun 84 and creat 3.6. urine output approx 100cc/hr.\n\nneuro: pt is following simple commands---upon request pt opened eyes and was able to wiggle toes. continues restrained. pupils 3mm/3mm--the right pupil sluggish and left pupil brisk.\n\nheme: hct 31.1 and plt 237.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-23 00:00:00.000", "description": "Report", "row_id": 1266260, "text": "MICU-NPN\n\nNEURO: Pt. responds to verbal stimuli. Follows simple commands, inconsistantly. Pt. off all sedation but did require Ativan x2 over noc for increased agitation that did not resolve on it's own.\nCV: Tmax: 99.4po, ABP 130's-190's, extremities very edmatous, + doppler PP.\nRESP: no vent changes made over noc. LS coarse, suctioned for small amt's of thick, yellow sputum.\nGI: abdomen slightly firm and distended, no stool over noc, +BS. TF infusing @ goal with no residuals.\nGU: Foley drng. adequate amt's of cloudy, yellow urine.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-23 00:00:00.000", "description": "Report", "row_id": 1266261, "text": "pmicu nursing progress note\nid: temp at 8a was 99.8po, at 12p 99.3po and at 4p 101.7 rectally---urine, sputum, blood and stool sent for culture. wbc was 12.9. continues to receive levo and zosyn. sputum sent yesterday has yeast and pseudomonas.\n\ncardiac: bp 125-176/50-60 with a pulse of 55-58avpaced, with some beats initiated o own. but when pt physically stimulated bp becomes elevated to a high of 210/74 with a pulse of 60-68. at 6p bp noted to be hovering around 100/42--? why--no meds or sedation given to pt. no ectopy noted--k+ 4.1. hands very edematous\n\nresp: current vent settings are ac 40% tv 800 x14 vented breathes with 1-3 spont breathes and 5 peep (pp 35)---abg was 93 38 7.39 and 72 44 7.36 26 and 0. lung sounds are deminished, slightly coarse on the left. suctioned several times for a moderate amt of thick white/yellow sputum.\n\ngu: foley in place. bun 83 and creat 3.2. urinary output approx 80cc/hr.\n\ngi: abdomin soft/distended---?more distended today. no aspirates obtained from the ng. promote with fiber is infusing, at goal, at 75cc/hr. passing soft brown, ob neg, stool.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-15 00:00:00.000", "description": "Report", "row_id": 1266243, "text": "MICU/SICU NPN HD #3\nS/O:\n\nNeuro: remains sedated on fentanyl/Ativan, eyes open to stimulation, will answer yes/no questions by nodding head, MAE nonpurposefully\n\nResp: continues on AC 18x650x0.50 +15, last ABG 7.40/101/38/24/0, LS diminised in all anterior fields, posterior field occasional wheezes, fine rales, suctioned q3h for small amts thick tan sputum\n\nCV: remains hemodynamically stable on renal dose dopamine, AV paced rhythm, please see flowsheet for data\n\nSkin: C/W/D/I, on BariAir rotating bed\n\nGI/GU: abd soft, distended, BS present, NGT to LIS draining green bilious fluid, Foley patent for clear yellow urine in adequated amts\n\nLines: right IJ TLCL, right radial art line\n\nID: remains afebrile, continues on levofloxacin and Zosyn\n\nSoc/Disp: meeting with daughter anticipated for to discuss plan of care and code status\n\nA:\n\naltered breathing r/t increased resp secretions\nhigh risk for infection r/t invasive lines\naltered nutrition r/t poor caloric intake > 3 days\nhigh risk for injury r/t sedation. invasive lines ETT\n\nP:\n\ncontinue to monitor hemodynamic stability, continue abx as ordered, nutrition c/s to evaluate need for parenteral nutrtion, continue to wean sedation as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2105-08-15 00:00:00.000", "description": "Report", "row_id": 1266244, "text": "Respiratory Care Note:\n Patient remains sedated on ativan and fentanyl, and intubated # 8ET tube secured 23cm at lip. BS are equal bilat, decreased t/o. Suctioned today for minimal amounts of yellow-tinged sputum. ABG improving this afternoon on A/C rate of 18 with minute volume of > 12lpm. (See CareVue Flow sheet). Tolerated increased rate without additional auto-peep.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-16 00:00:00.000", "description": "Report", "row_id": 1266245, "text": "NPN 7P-7A\nNeuro: Ativan increased to 3mg/hr, fentanyl increased to 150mcg/hr, due to increased agitation, twitching hands and setting off vent. Appears less restless now.\n\nResp: No vent changes over noc, continues on a/c 650x18, peep 15, fio2 50%, am gas 7.41/37/78/0/24. Sats. dropped to 85%, pt. was sx. for large plugg by resp, sedation was increased at this time. Sats are now 94%.\n\nCV:BP dropped to 82/43, dopa was increased to 2.2mcg/kg/min and 500cc ns fluids bolus was given. BP more stabe now 112/57. HR 55-60's av paced.\n\nGI: Abd.continue to be very firm abd disteneded, ngt to lis.\n\nGU: U/O > 45cc hr, urine is clear to cloudy.\n\nAccess: Proximal port of central line is leaking, md is aware and address it in the am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-08-16 00:00:00.000", "description": "Report", "row_id": 1266246, "text": "MICU/SICU NPN HD #4\nS/O:\n\nNeuro: remains sedated on fentanyl/Ativan, eyes open spontaneously, MAE nonpurposefully\n\nResp: continues on AC 18x650x0.50+15, LS coarse in upper lobes, dim at the bases, suctioned ~q3h for moderate amts thick tan secretions\n\nCV: remains on low dose dopamine, AV paced, please see flowsheet for data\n\nSkin: C/W/D/I, on BariAir rotating bed\n\nGI/GU: abd soft distended, BS absent, NGT to LIS draining green bilious fluid with pH 5, Foley patent for dark yellow urine in adequate amts\n\nLines: right IJ TLCL changed over wire today, righ radial art line, #22 angio left wrist\n\nID: afebrile, continues on Levo/Zosyn\n\nSoc/Disp: meeting with daughter today, pt is now DNR\n\nA:\n\naltered breathing r/t increased resp secretions\nhigh risk for infection r/t invasive line\naltered nutrition r/t poor caloric intake > 3 days\nhigh risk for injury r/t sedation, invasive lines, ETT\n\nP:\n\ncontinue to monitor hemodynamic stability, continue abx as ordered, nutrtion c/s to evaluate need for parenteral nutrtion\n" } ]

[ { "category": "Radiology", "chartdate": "2105-09-14 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 1251298, "text": " 9:16 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: DVT\n Admitting Diagnosis: NECK PAIN/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with right lower ext edema and pain behind the knee. no history\n of CHF\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with right lower extremity edema and pain behind\n the knee. No history of congestive heart failure or DVT.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Grayscale and Doppler son was performed of the right common\n femoral, superficial femoral, popliteal, posterior tibial and peroneal veins.\n Normal compressibility, flow and augmentation noted throughout. There is a\n 7.9 x 3.1 x 2.9 cm cyst in the right popliteal fossa, a portion of\n which appears slightly irregular, possibly due to a small rupture. Minimal\n edema noted in soft tissue of right calf.\n\n IMPRESSION: No right lower extremity deep vein thrombosis. cyst in\n the right popliteal fossa with an area of irregularity possibly representing\n rupture.\n\n" }, { "category": "Radiology", "chartdate": "2105-09-08 00:00:00.000", "description": "CERVICAL SINGLE VIEW IN OR", "row_id": 1250664, "text": " 3:52 PM\n CERVICAL SINGLE VIEW IN OR ; CERVICAL SINGLE VIEW IN OR Clip # \n -76 BY SAME PHYSICIAN\n : ANT. C3-5 FUSION\n Admitting Diagnosis: NECK PAIN/SDA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fusion.\n\n FINDINGS: Images from the operating suite show an anterior fusion at C3\n through C5. Further information can be gathered from the operative report.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1250689, "text": " 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 52 year old man with NGT, please evaluate for placement and\n Admitting Diagnosis: NECK PAIN/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with NGT, please evaluate for placement and air in mediastinum\n after repair\n REASON FOR THIS EXAMINATION:\n 52 year old man with NGT, please evaluate for placement and air in mediastinum\n after repair\n ______________________________________________________________________________\n WET READ: KKgc TUE 9:08 PM\n ETT tip 3.8 cm above carina. Dobhoff tube in the proximal stomach, just below\n GE junction. No pneumomediastinum or pneumoperitoneum. Right lung is\n partially imaged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible air in mediastinum after repair.\n\n FINDINGS: No previous images. Endotracheal tube tip lies approximately 3.8\n cm above the carina. The Dobbhoff tube straddles the esophagogastric junction\n with much of the metallic portion in the distal esophagus. This tube should\n be pushed forward. No evidence of pneumomediastinum or pneumoperitoneum,\n though this is not fully erect image. Cardiac silhouette is essentially\n within normal limits. There is some indistinctness of engorged pulmonary\n vessels consistent with elevated pulmonary venous pressure.\n\n The outer most portion of the right lung has been excluded from the image.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1250861, "text": " 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: NECK PAIN/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with pod2 with fever\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Fever and pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the tip of the nasogastric\n tube is at the level of the gastroesophageal junction. The lung volumes\n remain low. There are unchanged areas of atelectasis at the lung bases.\n Moderate cardiomegaly without overt pulmonary edema. No newly appeared focal\n parenchymal opacities that could represent pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-09-09 00:00:00.000", "description": "P C-SPINE NON-TRAUMA 2-3 VIEWS PORT", "row_id": 1250739, "text": " 8:42 AM\n C-SPINE NON-TRAUMA VIEWS PORT Clip # \n Reason: 52 year old man with removal of ACDF hardware, please evalau\n Admitting Diagnosis: NECK PAIN/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with removal of ACDF hardware, please evalaute for remaining\n hardware.\n REASON FOR THIS EXAMINATION:\n 52 year old man with removal of ACDF hardware, please evalaute for remaining\n hardware.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Removal of ACDF hardware. Please evaluate for remaining hardware.\n\n Three views of the cervical spine were obtained portably in the OR.Views dated\n at 8:53 a.m. presented now for official interpretation.\n\n Support tubing is present, including an NG/OG-type tube that is coiled in the\n retropharynx. Compared with at 15:56 p.m., the anterior plate and\n screws have been removed. No residual metallic hardware is identified. There\n is apparent residual fusion material at the C3/4 and C4/5 disc levels. The C5\n and lower vertebral body and disc spaces are obscured by overlying anatomy on\n the lateral view.\n\n IMPRESSION: Interval removal of metallic hardware from anterior cervical\n spine.\n\n" }, { "category": "Radiology", "chartdate": "2105-09-15 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1251421, "text": " 9:13 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: 52 year old man with pharyngeal tear s/p repair\n Admitting Diagnosis: NECK PAIN/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with pharyngeal tear s/p repair\n REASON FOR THIS EXAMINATION:\n 52 year old man with pharyngeal tear s/p repair\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with pharyngeal tear status post repair.\n Evaluate for leak.\n\n COMPARISONS: Comparison video oropharyngeal swallow from .\n\n FINDINGS: Video oropharyngeal swallow was performed in conjunction with the\n speech and swallow division. Initial lateral and AP views were obtained while\n the patient ingested thin barium. However, these were insufficient to\n determine leak. Soft tissue swelling was noted in the retropharyngeal space.\n There was trace penetration with thin liquids.\n\n Subsequently, rapid pharyngogram was obtained in both the lateral and AP\n position. There was no large leak or collection of thin barium. However,\n irregularity along the left pharyngeal folds (adjacent to the visible drain)\n probably related to recent tear and subsequent intervention makes it difficult\n to exclude a small leak. Barium passed into the esphagus without evidence of\n obstruction however, there was significant residue within the piriform\n sinuses. Narrowing was noted at the UES and the upper esophagus.\n\n IMPRESSION:\n\n 1. No large leak or collection of barium is visible, however, small leak\n along the left pharyngeal mucosa cannot be excluded.\n\n 2. Trace penetration with thin liquids. See also the note from the Speech\n Pathology division in the electronic medical records for further assessment\n and recommendations.\n\n These findings were discussed with Dr. by Dr. via telephone\n at 10:30 a.m.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2138-08-08 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1203506, "text": " 9:18 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: SP LIVER RESECTION ,EVAL FOR HEPATIC AND PV FOR STASIS/PATENCY\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HCC\n REASON FOR THIS EXAMINATION:\n hepatic and portal vein for stasis/patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 49-year-old man with HCC, status post hepatic resection,\n evaluate hepatic and portal veins for stasis/patency.\n\n COMPARISON: Doppler ultrasound, .\n\n FINDINGS: No focal abnormality is seen within the liver. No biliary\n dilatation is seen and the common duct measures 0.5 cm. No fluid collection\n is seen in the right upper quadrant.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main, right and left portal veins are patent with hepatopetal\n flow. The hepatic veins are patent. Appropriate flow is seen in the main\n hepatic artery.\n\n IMPRESSION:\n 1. The portal veins are patent and demonstrate forward flow, which is a\n change from the prior ultrasound when reverse flow was demonstrated. The\n hepatic veins are also patent.\n\n 2. No focal hepatic abnormality identified. No biliary dilatation is seen.\n No fluid collection in the right upper quadrant.\n\n" }, { "category": "Radiology", "chartdate": "2138-08-04 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1202970, "text": " 3:08 PM\n DUPLEX DOPP ABD/PEL PORT; ABDOMEN U.S. (COMPLETE STUDY) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: S/P LIVER RESECTION, CK PORTAL VEIN THROMBOSIS\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with HCC, ETOH.\n REASON FOR THIS EXAMINATION:\n assess for portal vein thrombosis.\n ______________________________________________________________________________\n WET READ: GMSj MON 6:12 PM\n Patent main, right and left portal veins. However, reversal of flow in the\n main portal vein and its branches (now hepatofugal)- findings new compared to\n prior OSH ultrasound from .\n\n Mild to moderate intra-abdominal ascites.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old male with cirrhosis and hepatocellular carcinoma. The\n patient is status post recent resection of a segment VII lesion. Evaluation\n for portal vein thrombosis.\n\n COMPARISON: Preoperative CT abdomen from and preoperative\n outside hospital abdominal ultrasound from .\n\n RIGHT UPPER QUADRANT DOPPLER ULTRASOUND: Limited views of the liver\n demonstrate increased echogenicity, findings consistent with cirrhosis. No\n definite hepatic lesion is identified on this limited exam. Doppler\n evaluation of the main, left, and right portal veins demonstrates wall-to-wall\n color flow without evidence of thrombosis. However, there is reversal of flow\n in all of the branches of the portal vein, findings which are new compared to\n prior outside hospital ultrasound from . The hepatic veins are\n patent with normal directional flow. The spleen remains enlarged measuring 17\n cm. Limited views of both kidneys demonstrate no hydronephrosis. There is a\n moderate amount of intra-abdominal ascites in the right and left lower\n quadrants. The common bile duct measures 3 mm.\n\n IMPRESSION:\n 1. Patent portal venous system; however, new reversal of flow in the main,\n left, and right portal veins.\n 2. Moderate intra-abdominal ascites.\n 3. Stable splenomegaly.\n\n" }, { "category": "Echo", "chartdate": "2138-09-13 00:00:00.000", "description": "Report", "row_id": 64650, "text": "PATIENT/TEST INFORMATION:\nIndication: volume status.plueral effusion.\nHeight: (in) 71\nWeight (lb): 184\nBSA (m2): 2.04 m2\nBP (mm Hg): 97/48\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 13:18\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. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient.\nMid-cavitary gradient. No VSD.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thicknesses and cavity size are normal.\nRegional left ventricular wall motion is normal. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). A mid-cavitary gradient is identified.\nThere is no ventricular septal defect. The right ventricular cavity is mildly\ndilated with normal free wall contractility. The diameters of aorta at the\nsinus, ascending and arch levels are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion. There is no valvular\naortic stenosis. The increased transaortic velocity is likely related to high\ncardiac output. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-09-03 00:00:00.000", "description": "REDUCED SERVICES", "row_id": 1207234, "text": " 9:03 PM\n MRI ABDOMEN W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: Please assess liver vasculature with contrast, especially ri\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man s/p resection of segment VII on c/b high volume\n ascites, h/o Hep C and ETOH, hepatology now recommending TIPS but given seg VII\n resection need to evaluate proximity of RHV to liver parenchyma and other\n structures\n REASON FOR THIS EXAMINATION:\n Please assess liver vasculature with contrast, especially right hepatic vein\n for feasibility of placing TIPS on right system\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Limited MR of the abdomen.\n\n COMPARISON: Reference is made to a recent CT of the chest without contrast of\n and a preoperative CTA of the abdomen dated .\n\n DATE OF STUDY: .\n\n TECHNIQUE: Limited multiplanar T2 coronal HASTE images were performed. The\n patient could not tolerate further sequences due to respiratory difficulties\n and claustrophobia. Only 36 images coronal images were obtained.\n\n FINDINGS:\n Limited T2 only coronal images of the liver demonstrate a right-sided pleural\n effusion, small volume ascites and subcutaneous edema.\n Patient is status post segment VII liver resection and there is a 7 x 7.5 cm\n fluid collection adjacent to the resection bed. This has not changed\n significantly in size since the prior CT. A normal flow void is seen in the\n main portal, left portal, and right anterior portal vein. Flow void is not\n seen within the right posterior portal vein; however, this is felt to be\n artifactual however correlation with Doppler ultrasonography is advised. The\n common duct is normal in caliber measuring 5 mm. There is no intrahepatic\n biliary dilatation. Similarly, the pancreatic duct is normal in caliber.\n\n IMPRESSION:\n 1. Markedly limited study due to factors described. Within these limits, the\n main, left and right anterior portal veins are patent. Signal seen within the\n right posterior portal vein is likely artifactual, however, correlation with\n Doppler son is advised to confirm.\n 2. Stable fluid collection adjacent to the hepatic resection site.\n 3. Right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2138-09-08 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1207918, "text": " 8:44 AM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Evaluate patency\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with s/p TIPS\n REASON FOR THIS EXAMINATION:\n Evaluate patency\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: Abdominal ultrasound with Doppler.\n\n INDICATION: Status post TIPS, assess vasculature and TIPS shunt for patency.\n\n COMPARISON: Ultrasound abdomen with Doppler dated .\n\n TECHNIQUE: TIPS shunt is visualized extending from the main portal vein\n through the liver parenchyma into the right hepatic vein. Very rapid flow\n (exceeding 220 cm/s) is observed in the proximal portion of the TIPS shunt,\n suggestive of kinking or narrowing.\n\n Velocity within the mid and distal TIPS are within normal range and measures\n 150 cm/sec and 130 cm/sec respectively. Hepatic veins, main hepatic artery\n and branches are visualized and patent with appropriate waveform and direction\n of flow.\n\n Expected reversal of flow is observed in the left and anterior right portal\n vein. The posterior right portal vein is not well visualized and unabled to be\n assessed by Doppler.\n\n Pleural effusion is visualized posterior to the right hepatic lobe. Ascites\n is seen within the right lower and left lower quadrant.\n\n IMPRESSION:\n\n 1. Abnormally high flow seen in the proximal TIPS shunt, suggestive of\n narrowing or kinking. Dr. was called at 9:50 a.m. by to\n relate this finding.\n\n 2. Tip shunt is visualized entering the distal portal vein extending through\n the liver parenchyma into the right hepatic vein. TIPS appears patent with\n flow in the mid and distal aspects ranging from 130 to 150 cm/sec.\n\n 3. Ascites seen in right lower and left lower quadrant. Pleural effusion is\n visualized behind the right hepatic lobe.\n\n" }, { "category": "Radiology", "chartdate": "2138-09-15 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1209016, "text": " 3:58 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Assess lung expansion post doxycycline infusion\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with chronic right lung fluid, s/p VATS on and now\n doxycycline infusion today\n REASON FOR THIS EXAMINATION:\n Assess lung expansion post doxycycline infusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 49-year-old man with chronic fluid in right lung status\n post VATS, now on doxycycline infusion. Please assess lung expansion, status\n post doxycycline.\n\n COMPARISON: Chest radiograph from 8:53 on the same day.\n\n FINDINGS: In comparison with the prior chest radiograph, there is little\n overall change. Cardiomediastinal silhouette and hilar contours are\n unchanged. There is some evidence of increased opacity bilaterally. There\n are no pleural effusions. The central venous line is seen in unchanged and\n correct position.\n\n\n" }, { "category": "ECG", "chartdate": "2138-09-17 00:00:00.000", "description": "Report", "row_id": 134728, "text": "Moderate baseline artifact. Sinus tachycardia. Diffuse non-specific ST-T wave\nchanges. Compared to the previous tracing of no diagnostic interval\nchange.\n\n" }, { "category": "ECG", "chartdate": "2138-09-08 00:00:00.000", "description": "Report", "row_id": 134729, "text": "Baseline artifact. Sinus rhythm at upper limits of normal rate. Possible\nST-T wave abnormalities. Since the previous tracing of ST-T wave\nabnormalities may be more marked but both tracings have considerable artifact.\nClinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2138-09-05 00:00:00.000", "description": "Report", "row_id": 134730, "text": "Marked baseline artifact. Within the constraints of the baseline artifact\ntracing is probably within normal limits. Compared to the previous tracing\nof there is probably no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2138-09-04 00:00:00.000", "description": "Report", "row_id": 134731, "text": "Sinus tachycardia with increase in rate as compared with prior tracing\nof . Variation in precordial lead placement. Non-specific ST-T wave\nchanges in the limb leads. There is prominent lateral precordial voltage for\nleft ventricular hypertrophy. Otherwise, no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2138-09-03 00:00:00.000", "description": "Report", "row_id": 134732, "text": "Sinus rhythm. Variation in precordial lead placement as compared with prior\ntracing of . Wandering baseline and baseline artifact. There is delayed\nprecordial R wave transition and more prominent lateral ST-T wave flattening.\nOtherwise, no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2138-08-18 00:00:00.000", "description": "Report", "row_id": 134733, "text": "Sinus tachycardia. Otherwise, normal tracing. Compared to the previous\ntracing of the rate has increased. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "Radiology", "chartdate": "2138-09-06 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1207730, "text": " 9:00 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate interval change, obtain image at 2100 today\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with R pneumothorax and effusion\n REASON FOR THIS EXAMINATION:\n Evaluate interval change, obtain image at 2100 today\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST X-RAY, .\n\n COMPARISON: Radiograph of earlier the same date.\n\n FINDINGS: Large right pleural effusion with intrafissural extension appears\n similar to the previous study. Apparent elevation of right hemidiaphragm may\n reflect a subpulmonic component of the effusion. Right pneumothorax has\n nearly resolved. Exam is otherwise unchanged since recent study.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-09-04 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1207297, "text": " 9:24 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please perform RUQ duplex/ultrasound to evaluate the patency\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with alcoholic/HCV-related cirrhosis and HCC s/p segment VII\n resection complicated by increased ascites and now with persistent R. pleural\n effusion with plan for TIPS procedure\n REASON FOR THIS EXAMINATION:\n Please perform RUQ duplex/ultrasound to evaluate the patency of the hepatic\n vasuclature: in particular please evlauate the patency of the R. hepatic vein\n and L. hepatic vein to assist in planning for TIPS procedure\n ______________________________________________________________________________\n WET READ: 10:39 AM\n 1. Patent hepatic vessels with antegrade flow.\n 2. 8x8x3cm right upper quadrant air and fluid collection as on the recent CT\n though perhaps slightly smaller.\n 3. Right pleural effusion and small volume ascites.\n 4. Splenomegaly and cirrhosis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and HCC status post resection with persistent effusion\n and increased ascites. Plan for TIPS, assess vasculature for patency.\n\n TECHNIQUE: Abdominal ultrasound with Dopplers.\n\n COMPARISON: CT chest . Liver ultrasound .\n\n FINDINGS: Coarsened liver is consistent with cirrhosis. No focal hepatic\n lesions are seen. Patient is status post segment VII resection with a 7.7 x\n 7.7 x 3.3 cm air-fluid collection in the resection bed slightly decreased in\n size. There is no intra- or extra-hepatic biliary ductal dilatation. The\n common bile duct is not dilated, measuring 5 mm. The gallbladder is\n surgically absent. The spleen is again noted to be enlarged to 18.3 cm.\n There is a small volume of ascites. Large right pleural effusion is again\n seen. Duplex son imaging of the hepatic vasculature was performed.\n The hepatic veins, main portal vein and its branches, and main hepatic artery\n are patent with appropriate waveforms and directionality of flow.\n\n IMPRESSION:\n 1. Patent hepatic vessels.\n 2. Small volume ascites and large right pleural effusion.\n 3. Splenomegaly with cirrhotic liver.\n 4. 8-mm air and fluid collection in the surgical resection bed slightly\n smaller than on the recent CT.\n (Over)\n\n 9:24 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please perform RUQ duplex/ultrasound to evaluate the patency\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2138-09-04 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1207334, "text": " 12:06 PM\n TIPS Clip # \n Reason: Please place new TIPS\n Admitting Diagnosis: LIVER MASS/SDA\n Contrast: VISAPAQUE Amt: 105\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * -59 DISTINCT PROCEDURAL SERVICE US GUID FOR VAS. ACCESS *\n * -59 DISTINCT PROCEDURAL SERVICE INSERT HEPATIC HUNT TIPS *\n * -59 DISTINCT PROCEDURAL SERVICE PLEURAL ASP BY RADIOLOGIST *\n * GUIDANCE/LOCALIZATION FOR NEEDLE BIO -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with alcoholic/HCV-related cirrhosis and HCC s/p resection of\n mass in segment VII of the liver complicated by high ascites output and now\n with persistent R. pleural effusion likely secondary to his hepatic disease.\n RUQ ultrasound has been obtained to evaluate the patency of his hepatic\n vasculature (due to his prior segment VII resection the L. hepatic vein may\n have been compromised but access should still be possible via the R. hepatic\n vein)\n REASON FOR THIS EXAMINATION:\n Please place new TIPS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old man with cirrhosis and HCC status post resection of\n segment VII liver mass complicated by high ascites output and persistent right\n pleural effusion.\n\n CLINICIANS: Dr. (fellow), Dr. (resident) and Dr.\n (attending) performed the procedure. The attending physician was\n present, supervising and performing all portions of the procedure.\n\n ANESTHESIA: The patient was intubated and general anesthesia was provided.\n\n PROCEDURES:\n 1. Ultrasound-guided right IJ puncture.\n 2. Right-sided thoracentesis.\n 3. Transjugular intrahepatic portosystemic shunt.\n 4. Right IJ triple-lumen central catheter placement.\n\n PROCEDURE AND FINDINGS: Written informed consent was obtained from the\n patient after explaining the indications, risks, benefits, and alternatives to\n the procedure. The patient was transferred to the angiography suite and\n placed supine on the imaging table. After induction of anesthesia, the right\n neck was prepped and draped in the usual sterile fashion. A preprocedure\n huddle and timeout were performed as per protocol.\n\n Under aseptic conditions, the right internal jugular vein was accessed using a\n micropuncture needle under ultrasound guidance. A 0.018 nitinol wire was\n easily advanced into the SVC under fluoroscopic guidance. A small skin\n incision was made at the needle entry site. A 4-French micropuncture sheath\n was exchanged for the needle. Inner dilator and wire were removed and a 0.035\n (Over)\n\n 12:06 PM\n TIPS Clip # \n Reason: Please place new TIPS\n Admitting Diagnosis: LIVER MASS/SDA\n Contrast: VISAPAQUE Amt: 105\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n wire was advanced into the low SVC. A large right pleural effusion\n was causing significant mass effect on the heart and mediastinum making\n passage of the catheter into the IVC difficult.\n\n At this time the right chest was cleaned in sterile fashion to perform a\n thoracentesis. Ultrasound confirmed a large right effusion and a proper\n location was marked. A 5-French catheter was advanced into the pleural\n space in the mid clavicular line over the superior edge of a lower thoracic\n rib. 4 liters of amber fluid was easily aspirated.\n\n At this point, attention was returned to the internal jugular venous access\n site. The wire was now easily advanced into the IVC and the course was\n straight. The venotomy tract was serially dilated using 6-, 10- and 12-French\n dilators. A 12-French sheath was then advanced over the guidewire into\n the IVC. Right atrial pressure was measured as 6 mmHg. The middle hepatic\n vein was selectively cannulated using a 5-French MPA catheter. The position\n was confirmed with AP and lateral fluoroscopy. Next, an occlusion balloon was\n passed over the wire, and inflated in the central hepatic vein. The balloon\n was inflated and right hepatic wedge pressure was measured as 25 mmHg\n corresponding to a preprocedure portosystemic gradient of 19 mmHg. A CO2\n portogram was performed in both AP and lateral projections demonstrating\n satisfactory patency of the portal system.\n\n The wire was exchanged for an Amplatz wire and a curved -\n needle was then advanced. The needle was directed posteriorly and\n transparenchymal puncture was performed. Contrast was injected as the needle\n was retracted in an attempt to opacify the portal vein. At one point, a portal\n vein branch was opacified, but a wire could not be passed into the main portal\n vein. After three unsuccessful attempts, the right hepatic vein was selected.\n The - needle was directed anteriorly and transparenchymal puncture\n was again performed. After two passes, successful catheter position within\n the right portal vein was achieved. A 0.035 Glidewire was successfully\n advanced into the main portal vein. 5-French flush catheter was advanced over\n the Glidewire and used to perform a digital subtraction portogram. The portal\n pressure was measured as 26 mmHg, which correlated well with the previously\n measured hepatic vein wedge pressure. A stiff Amplatz wire was exchanged and\n a 10 mm x 7 cm (covered) plus 2 cm (uncovered) Viatorr stent was passed over\n the wire through the parenchymal tract. The stent was successfully deployed\n and further expanded with a 10 mm x 4 cm balloon. A flush catheter was\n again placed in the main portal vein and a digital subtraction portogram was\n placed confirming TIPS shunt patency. Portosystemic gradient was remeasured\n as 8 mmHg. Based on the findings of the digital subtraction angiogram, the\n decision was made to place an additional stent proximally at the hepatic vein\n exit site. A 12 mm x 60 mm Luminexx stent was expanded at the hepatic vein\n site of the TIPS using a 12 x 4 cm Atlas balloon. The final portosystemic\n (Over)\n\n 12:06 PM\n TIPS Clip # \n Reason: Please place new TIPS\n Admitting Diagnosis: LIVER MASS/SDA\n Contrast: VISAPAQUE Amt: 105\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gradient was measured as 8 mmHg. A final digital subtraction portogram was\n performed.\n\n After terminating the placement of the TIPS shunt, anesthesiologist informed\n us that venous access was desired. A 16 cm 7-French triple-lumen central\n catheter was passed over the wire with the tip positioned in the low SVC. It\n was secured in place with 0 silk suture. A 0 silk pursestring suture was\n placed around the venotomy site to prevent oozing of blood. Dry clean\n dressing was applied.\n\n A 0 silk pursestring suture was placed around the catheter in the right\n chest. The catheter was removed from the thoracentesis site while applying\n traction on the pursestring. Lubricated dressing was applied.\n\n IMPRESSION:\n 1. Successful placement of a TIPS with final portosystemic gradient of 8\n mmHg.\n 2. Successful thoracentesis of 4 liters of fluid.\n 3. Successful placement of a triple-lumen central line.\n\n Findings were discussed with Dr. in person at 5:50 p.m. on\n .\n\n" }, { "category": "Radiology", "chartdate": "2138-09-09 00:00:00.000", "description": "RELATED PROCEDURE DURING POSTOPERATIVE PERIOD", "row_id": 1208135, "text": " 10:40 AM\n PORTAL VENOGRAPHY Clip # \n Reason: TIPS placed for continuing ascites and pleural effusion\n Admitting Diagnosis: LIVER MASS/SDA\n Contrast: VISAPAQUE Amt: 30\n ********************************* CPT Codes ********************************\n * PERC PORTAL VEIN CATH -78 RELATED PROCEDURE DURING POSTOPE *\n * PERC TRANHEP PORTOGRAPHY WITH MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with TIPS placed and abnormal findings on U/S \n REASON FOR THIS EXAMINATION:\n TIPS placed for continuing ascites and pleural effusion. U/S today reveals\n \"abnormally high flow seen at proximal shunt\", please perform TIPS venogram to\n assess for kinking or narrowing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is status post TIPS and continues to have right\n pleural effusion. Ultrasound reveals abnormally high flow seen at the\n proximal shunt. Please perform tips venogram to assess for patency.\n\n OPERATORS: Dr. and Dr. (attending physician\n was present for and participated in the entire the procedure.)\n\n PROCEDURE: Written informed consent was obtained from the patient after\n explaining the risks, benefits, alternatives and the procedure in detail. The\n patient was brought to the angio suite and placed supine on the table. The\n right side of the neck was prepped and draped in a sterile fashion. A\n preprocedural huddle and timeout were performed per protocol.\n\n The right internal jugular vein was accessed under ultrasound guidance and the\n wire was passed through and confirmed to be in the SVC by fluoro. (The\n existing triple lumen right IJ catheter was not used as the patient had no\n other venous access.) The needle was then exchanged for microsheath and the\n dilator and guidewire were removed and was introduced and it was passed\n into the IVC. Then, the micropuncture sheath was exchanged with a 7 French 35\n cm tip sheath which was extended toward the hepatic vein. A 5FR MPA\n catheter was extended over the and the hepatic vein was cannulated\n with the MPA catheter and J-wire was attempted to be passed through\n the TIPS shunt. Since this was not successful, we exchanged the MPA catheter\n for a multiholde straight catheter which was advanced into the portal vein.\n Portal venous pressure was measured just outside of the stent and later well\n into the portal vein. Pressures were also taken from the mid shunt, the IVC\n just distal to the shunt and right atrium pressures. The pressures were taken\n through the 7 French sheath. Then, a portovenogram was performed through the\n flush catheter which showed a widely patent C shape TIPS shunt with no evident\n stenosis or kinking of the shunt.\n\n All wires and catheters and sheaths were removed and manual pressure was held\n at the right IJ access point for 5 minutes. There was no hematoma or\n extravasation seen. Sterile dressings were applied. The patient tolerated\n (Over)\n\n 10:40 AM\n PORTAL VENOGRAPHY Clip # \n Reason: TIPS placed for continuing ascites and pleural effusion\n Admitting Diagnosis: LIVER MASS/SDA\n Contrast: VISAPAQUE Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the procedure well. There were no immediate complications.\n\n FINDINGS:\n TIPS stent appears well-expanded and in unchanged \"c\" formation compared to\n the placement exam. Venography shows brisk hepatopetal flow up the stent\n and into the hepatic vein and right atrium with no intrahepatic portal venous\n opacification. Portal venous pressure was measured as 17mmHG and right atal\n pressure was 9mmHg for a portosytemic gradient of 8mmHg, unchanged from time\n of placement.\n\n IMPRESSION:\n 1. Widely patent C shape TIPS shunt present.\n 2. Mean right atrial pressure of 9 mmHg and a portal pressure of 17 mmHg with\n the gradient of 8 mmHg, which is the same as the post-TIPS which was performed\n on .\n 3. Large right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2138-09-17 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1209396, "text": " 5:43 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: effusion/pneumo\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with recent removal of chest tube\n REASON FOR THIS EXAMINATION:\n effusion/pneumo\n ______________________________________________________________________________\n WET READ: WED 11:03 PM\n No evidence of pneumothorax. Persistent fluid in the minor fissure. Low lung\n volumes with minimal bibasilar atelectasis, right greater than left. Right IJ\n catheter ends in the mid-to-low SVC.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: Chest tube removed, assess pleural effusion.\n\n IMPRESSION: PA and lateral chest compared to through 28 at 11:09\n a.m.:\n\n Small to moderate right pleural effusion is unchanged since earlier in the day\n following removal of the right basal pleural tube with basal and fissural\n components. Consolidation at the medial aspect of the right lung base is\n probably atelectasis, unchanged. Left lung is grossly clear. Heart size is\n top normal, slightly larger now than earlier in the day. Central venous line\n ends in the SVC. No pneumothorax.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2131-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424441, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she presented to the OSH. EKG there revealed Ant/Lat STE. She was\n transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. LM-nl, Lcx w mild dz, 50% mid RCA. Peak CPK: 6300, Troponin:\n 8.4.\n Pt tx CCU for further management s/p .\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking. Per pt, she and her\n friend were going to quit for the New Year.\n Action:\n Cardiac teaching including MI, stent and medications. Smoking\n cessation information reviewed.\n Response:\n Pt states that she is going to change her ways, as of now. .\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n craving. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down.\n Action:\n Appropriate grieving, as pt is weepy today. Ativan given for IABP\n removal. Friend in to visit, who is very supportive of pt. SW\n in to visit, but pt was sleeping at that time\n Response:\n Appreciative of support\n Plan:\n Follow up with SW tomorrow. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMII)\n Assessment:\n MI with large CPK/troponin bump without further CP. Lungs with\n diminished breath sounds in bases to clear. Sats >94% as pt self dc\n her O2. Bilat groins d/I post sheath removal\n Action:\n Rec\nd first dose of Captopril 12.5mg this am. Heparin dc\nd at 1100\n for IABP dc\nd at 1330 . Swan dc\nd at 1800\n Response:\n Tolerated IABP removal w/ subsequent CI 2.5.\n Plan:\n Monitor for CP, hemodynamics pre and post captopril administration and\n titrate as able. Monitor groins for change, increase activity as\n tolerated.\n Fever\n Assessment:\n T max 99.6 po. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. incentive spirometer at bedside. IV\ns re-sited per policy.\n All access sites clean, without signs of infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc spirometer.\n" }, { "category": "Physician ", "chartdate": "2131-10-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424520, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n IABP, swan and A line removed without complications\n Chest pain at 9:40pm (, SBP 120, HR 100s) pt sitting up, eating ice\n chips, relieved with NTG x 2. EKG unchanged.\n ROS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.9\nC (98.4\n HR: 91 (88 - 107) bpm\n BP: 93/55(64) {87/43(58) - 126/67(77)} mmHg\n RR: 24 (15 - 33) insp/min\n SpO2: 95% NC\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n Last in early afternoon:\n PAP: (39 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.4 L/min) / (3 L/min/m2)\n SvO2: 65%\n Mixed Venous O2% Sat: 65 - 65\n Total In:\n 1,696 mL\n PO:\n 1,280 mL\n TF:\n IVF:\n 416 mL\n Blood products:\n Total out:\n 1,885 mL\n 560 mL\n Urine:\n 1,885 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -189 mL\n -560 mL\n Physical Examination\n GEN\n HEENT\n CV: No new murmurs\n PULM: Crackles at bases\n ABD\n EXT\n NEURO\n Labs / Radiology\n 114 K/uL\n 10.9\n 129 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33\n 13.1 K/uL\n [image002.jpg]\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n 02:23 PM\n 08:00 PM\n 11:36 PM\n 04:27 AM\n 04:45 AM\n 03:36 PM\n WBC\n 13.5\n 13.1\n Hct\n 36\n 36\n 33.0\n 34\n 34\n 34\n 30.2\n 33\n 33\n Plt\n 114\n 114\n Cr\n 0.8\n 0.9\n 0.7\n Glucose\n 189\n 138\n 129\n Other labs: PT / PTT / INR:15.1/110.5/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with HL and tobacco abuse pw chest pain and found to have\n a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: s/p large anterior infarct and stenting of LAD,\n initially cardiac index of 1.3 indicative of cardiogenic shock and\n requiring IABP.\n - IABP and swan removed yesterday after showing no more dependence (CI\n 3, MV0@ 65% and PAD 15 prior to removal)\n - Continues to do well without mechanical support\n BP and HR stable.\n - Coumadin started for low flow in area of akinetic/hypokinetic apex\n - ASA , statin 80 mg, plavix , Captopril\n - will add beta-blocker and spironolactone as tolerated by BP.\n - Daily EKGs\n .\n CHEST PAIN: similar in quality to prior CP but in setting of PO intake.\n - DDx: esophageal spasm, inflammatory, ACS.\n - ? recheck CEs.\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE\n Counseled by SW about smoking cessation.\n .\n THROMBOCYTOPENIA\n Platlets stable. Likely IABP.\n .\n HYPERLIPIDEMIA - continue statin at increased dose\n .\n FEN: Cardiac, No IVF, lytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DV: Warfarin, PPI\n CODE: full\n DISPO: CCU\n Active Medications , A\n 1. Warfarin 5 mg PO DAILY16\n 8. Morphine Sulfate 1-2 mg IV Q4H:PRN Pain\n 2. Nitroglycerin SL 0.3 mg SL PRN CP\n 9. Docusate Sodium 100 mg PO BID\n 3. Aspirin EC 325 mg PO DAILY\n 10. Ondansetron 4 mg IV Q8H:PRN Nausea\n 4. Atorvastatin 80 mg PO DAILY\n 11. Pantoprazole 40 mg PO Q24H\n 5. Captopril 12.5 mg PO TID\n 12. Senna 1 TAB PO BID:PRN\n 6. Clopidogrel 75 mg PO DAILY\n 13. Acetaminophen 325-650 mg PO Q6H:PRN Pain\n 7. Lorazepam 0.5-1 mg PO/IV Q4HPRN\n 14. Aluminum-Magnesium OH.-Simethicone 15-30mL prn\n" }, { "category": "Nursing", "chartdate": "2131-10-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424802, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Groins and peripheral pulses have remained\n stable/ intact, WNL. evening and evening-one episode of CP\n \\in setting of sitting up in chair- EKG without acute ischemic changes-\n pain d/c after 2 sl TNG. Pt anxious w pain and continues on Ativan PRN.\n Pt has had some intermittent hypotension w/ medication increases- \n lopressor was increased to 25mg tid and lisinopril was added. Most\n recent episode 5am requiring 250cc ivf bolus, Lopressor had been\n decreased to 12.5mg tid, but again increased to 25mg tid w/ low\n hold parameters. Lasix 20mg po added to regime.\n Increased activity evening- OOB to Chair x 1 hour after\n dangling. able to dangle and assist w/ am care, f/b oob to\n chair.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T current 97.6\n Action:\n Received Tylenol 650 mg po over night\n Response:\n normothermic\n Plan:\n Continue to follow for s/s infection d/t invasive procedures\n Anxiety/ Knowledge Deficit\n Assessment:\n Pt acknowledged that her life is stressful and needs to make some\n changes. Pt unable to identify meds and their actions\n Action:\n Medication review w/ each administration\n Response:\n Pt able to repeat information\n Plan:\n Continue teaching as this will decrease anxiety\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n BP continues 88-95/\n Action:\n Lopressor dose decreased to 12.5mg tid. Lopressor dose held at 0800\n and administered at 1000 as bp slightly higher\n Response:\n Pt\ns b/p 90\n Plan:\n Close hemodynamic monitoring. Stagger meds as necessary\n" }, { "category": "Nursing", "chartdate": "2131-10-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424752, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Groins and peripheral pulses have remained\n stable/ intact, WNL. evening and evening-one episode of CP\n \\in setting of sitting up in chair- EKG without acute ischemic changes-\n pain d/c after 2 sl TNG. Pt anxious w pain and continues on Ativan PRN.\n Pt has had some intermittent hypotension w/ medication increases- \n lopressor was increased to 25mg tid and lisinopril was added. most\n recent episode 5am requiring 250cc ivf bolus, subsequently\n Lopressor decreased to 12.5mg tid.\n Increased activity evening- OOB to Chair x 1 hour after\n dangling. able to dangle and assist w/ am care, f/b oob to\n chair.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T current 97.6\n Action:\n Received Tylenol 650 mg po over night\n Response:\n normothermic\n Plan:\n Continue to follow for s/s infection d/t invasive procedures\n Anxiety/ Knowledge Deficit\n Assessment:\n Pt acknowledged that her life is stressful and needs to make some\n changes. Pt unable to identify meds and their actions\n Action:\n Medication review w/ each administration\n Response:\n Pt able to repeat information\n Plan:\n Continue teaching as this will decrease anxiety\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n BP continues 88-95/\n Action:\n Lopressor dose decreased to 12.5mg tid. Lopressor dose held at 0800\n and administered at 1000 as bp slightly higher\n Response:\n Pt\ns b/p 90\n Plan:\n Close hemodynamic monitoring. Stagger meds as necessary\n" }, { "category": "Nutrition", "chartdate": "2131-10-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 424755, "text": "56 year old female admitted from OSH with STEMI, cardiac cath showed\n promximal LAD and 2 stents were placed to LAD. No nutrition risk is\n identified at this time. Pt screened per ICU protocol. Pt reports\n excellent appetite and po intake, no N/V no recent wt loss. Will f/u\n once pt is transferred to floor. Pls page with questions \n" }, { "category": "Nutrition", "chartdate": "2131-10-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 424758, "text": "56 year old female admitted from OSH with STEMI, cardiac cath showed\n promximal LAD and 2 stents were placed to LAD. No nutrition risk is\n identified at this time. Pt screened per ICU protocol. Pt reports\n excellent appetite and po intake, no N/V no recent wt loss. Will f/u\n once pt is transferred to floor. Pls page with questions \n ------ Protected Section ------\n Pt is on cardiac/heart healthy diet.\n ------ Protected Section Addendum Entered By: , RD\n on: 11:23 ------\n" }, { "category": "Physician ", "chartdate": "2131-10-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424863, "text": "TITLE:\n Chief Complaint:\n STEMI\n 24 Hour Events:\n Patient\ns SBPs have been in 70-90s. Received 250cc NS x 3 in past 18\n hrs. Added BB and switched from captopril to lisinopril.\n Temp 100.0 at MN, received APAP x 1, resolved.\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Other medications:\n ASA 325mg\n Plavix 75mg\n Lipitor 80mg\n Pantoprazole 40mg\n Lisinopril 10mg\n Coumadin 5mg\n Lopressor 25mg TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37\nC (98.6\n HR: 86 (79 - 109) bpm\n BP: 99/58(68) {74/43(50) - 124/6,756(92)} mmHg\n RR: 20 (10 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n Total In:\n 922 mL\n 590 mL\n PO:\n 672 mL\n 90 mL\n TF:\n IVF:\n 250 mL\n 500 mL\n Blood products:\n Total out:\n 2,115 mL\n 460 mL\n Urine:\n 2,115 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n 130 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN NAD, appears more comfortable\n HEENT MMM, JVP 8cm\n CV: No new murmurs or thrills, RRR\n PULM: Crackles at bases\n ABD soft, NT, ND, +BS, no HSM\n EXT no edema, WWP\n NEURO A+O x 3\n SKIN small left groin hematoma, no bruits or tenderness\n Labs / Radiology\n 168 K/uL\n 10.1 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 23 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.2 %\n 10.2 K/uL\n [image002.jpg]\n 05:04 AM\n 02:23 PM\n 08:00 PM\n 11:36 PM\n 04:27 AM\n 04:45 AM\n 03:36 PM\n 06:20 AM\n 08:34 PM\n 03:08 AM\n WBC\n 13.5\n 13.1\n 9.1\n 10.2\n Hct\n 33.0\n 34\n 34\n 34\n 30.2\n 33\n 33\n 30.6\n 29.2\n Plt\n 114\n 114\n 143\n 168\n Cr\n 0.9\n 0.7\n 0.8\n 1.0\n 0.9\n TropT\n 6.29\n Glucose\n 138\n 129\n 115\n 120\n 116\n Other labs: PT / PTT / INR:14.2/23.5/1.2, CK / CKMB /\n Troponin-T:167/4/6.29, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with HL and tobacco abuse pw chest pain and found to have\n a STEMI to an occluded LAD.\n CARDIOGENIC SHOCK: Improved. s/p large anterior infarct and stenting\n of LAD, initially cardiac index of 1.3 indicative of cardiogenic shock\n and requiring IABP.\n - Continues to do well without mechanical support\n BP and HR stable.\n Patient had low SBPs overnight, resolved with 250cc boluses x 3,\n likely sec to overdiursesis\n - Continue Coumadin\n - ASA , statin 80 mg, plavix, lisinopril\n - Continue BB\n CHF: pt fluid overloaded, will give lasix 20mg po daily.\n CHEST PAIN: Resolved.\n RHYTHM: NSR currently. Monitor on telemetry.\n TOBACCO ABUSE\n Counseled by SW about smoking cessation.\n THROMBOCYTOPENIA\n Platlets stable.\n HYPERLIPIDEMIA - continue statin at increased dose\n FEN: Cardiac, No IVF, lytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DV: Warfarin, PPI\n CODE: full\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:53 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": "2131-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424310, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n Remains CP free, awaiting wean and d/c of IABP as of . Doing well\n with ativan for restlessness r/t proglonged strict bedrest.\n Anxiety\n Assessment:\n Pt on bedrest since with some restlessness, anxiety.\n Action:\n Pt given ativan 0.5 mg x 2 doses, support, backrubs and position\n changes. Removed leg immoblizers for comfort.\n Response:\n Pt sleeping currently, appears comfortable, denies pain or anxiety.\n Plan:\n Continue to provide emotional support, teaching, frequent position\n change and backrubs while on strict bedrest. Ativan prn. Increase\n activity.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p large AMI currently hemodynamically stable on slow IABP wean.\n Action:\n Pt kept on IAPB 1:4. Started on Captopril 3.125 earlier in day-\n increased at qhs to 6.25 tid. Weaned to IABP x 1 hour to 1:8 with\n hemodynamics checked and unchanged.Heparin changed to 1350u from 1200u\n for PTT-51.\n Response:\n Pt remains hemodynamically stable, asymptomatic. CI/CO\n -2.4-2.7/4.5-4.9. MAPS-63-74, MVo2-61-66%. Systolic unloading 3-14 pts.\n PTT rechecked this AM on current Heparin dose. Groins/pulses stable.\n Good uo- 80-100cc/hour. Extremities warm. Denies pain of SOB.\n Plan:\n Continue to follow hemodynamics. Await AM rounds for plans re:\n removal/wean of IABP today. Increase captopril to 12.5 tid today. Check\n AM lytes- replete as needed, adjust heparin gtt as needed once AM PTT\n lab value back. Continue to teach/support pt. Increase activity as soon\n as medically appropriate.\n" }, { "category": "Physician ", "chartdate": "2131-10-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 423702, "text": "Chief Complaint: Chest pain, STEMI\n HPI: 56 y/o female with a h/o hyperlipidemia who presented to an OSH on\n the AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n Friday AM at work. The pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon, she again developed the\n same SSCP, this time radiating to her left arm, associated with nausea.\n Denied associated SOB. Pain persisted until Sunday AM when she finally\n presented to the OSH. EKG there revealed STE in V2-V4. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization. EKG at Hospital ED\n revealed a NSR, rate 86, STE in V2-6. STD in III. Normal axis.\n In the cath lab, she was found to have a totally occluded proximal LAD.\n She had two stents placed to her LAD. She then became hypotensive and\n was resuscitated with IVF. An IABP was placed along with a femoral\n Swan.\n Upon arrival to the CCU, she was hemodynamically stable and chest pain\n free. She had no complaints.\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were negative.\n Cardiac review of systems is notable for chest pain, dyspnea on\n exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Patient admitted from: Cath lab, transfer from OSH\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 500 units/hour\n Other ICU medications:\n Plavix 75 mg PO daily\n Lipitor 20 mg PO daily\n ASA 325 mg PO daily\n Other medications:\n Zofran PRN\n Morphine PRN\n Ativan PRN\n Past medical history:\n Family history:\n Social History:\n Hyperlipidemia\n Depression\n Tobacco Abuse\n Mother with MI at age 74. Sister and brother with .\n Occupation: Secretary\n Drugs: None\n Tobacco: cigarettes daily for the past 25 years\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\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 Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 94 (84 - 97) bpm\n BP: 107/58(68) {0/0(0) - 116/58(85)} mmHg\n RR: 20 (20 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n PAP: (43 mmHg) / (23 mmHg)\n CO/CI (Fick): (4 L/min) / (2.2 L/min/m2)\n SvO2: 67%\n Mixed Venous O2% Sat: 67 - 67\n Total In:\n 1,475 mL\n PO:\n TF:\n IVF:\n 1,475 mL\n Blood products:\n Total out:\n 0 mL\n 1,625 mL\n Urine:\n 1,625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -150 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Bases, No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 192 K/uL\n 13.2\n 139 mg/dL\n 1.0 mg/dL\n 19 mg/dL\n 26 mEq/L\n 99 mEq/L\n 4.2 mEq/L\n 136 mEq/L\n 39.3 %\n 13.8 K/uL\n [image002.jpg]\n \n 2:33 A11/9/ 01:27 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 13.8\n Hct\n 39.3\n Plt\n 192\n Cr\n 1.0\n TropT\n 7.95\n Glucose\n 139\n Other labs: PT / PTT / INR:13.6/34.3/1.2, CK / CKMB /\n Troponin-T:6137//7.95, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n # CORONARIES: Found to have a STEMI to an occluded LAD. LAD was\n stented, one in the proximal and one in the distal portion. After cath,\n she required the placement of an IABP and a femoral Swan.\n # PUMP: TTE tomorrow. Currently on IABP. Aim for LVEDP of 16-18.\n # RHYTHM: NSR currently. Monitor on telemetry.\n # Hyperlipidemia\n - continue statin\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n Arterial Line - 12:30 PM\n PA Catheter - 12:30 PM\n 20 Gauge - 12:30 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423758, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF.\n Pt tx CCU for further management s/p stemi.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Rec\nd pt pf on iabp 1:1 via r groin, although c/o nausea. HR 90\ns nsr\n w/ rare pvc\ns, MAP\ns 60\ns. PAD\ns 20-25. Card index improving to\n 2.2 then 2.9. O2 sats down to 92% on 5ln/p, Heparin 500units/hr w/\n PTT pnd. LE pulses palpable, first troponin post procedure 7.95\n (1.25), pt w/ inc anxiety, moving around in bed\n Action:\n Nausea rx w/ zofran, O2 changed to 100% NRB , CXR at 1745, pt flat in\n bed d/t bilat groin sheaths, bilat knee immobilizers in place, Ativan\n 1mg for restlessness/anxiety\n Response:\n Nausea relieved, O2 sats 97-100%, slept most of day w/ ativan\n Plan:\n Close hemodynamic monitoring, Lasix for continued pad\ns 25 and u/o,\n continue cycle ck\ns and tropoin and replete lytes prn, titrate heparin\n per PTT, check pnd cxr, turn and position for comfort, Ativan prn, keep\n pt and family informed of poc.\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423945, "text": "Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424206, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50%\n mid. Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking.\n Action:\n Medication teaching done on ASA, captopril and plavix. Reinforced\n efforts to stop smoking. HCP paper work signed by pt and placed in\n chart.\n Response:\n Understands purpose of medications, continues to express desire to quit\n smoking.\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n craving. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down. SW spoke with pt\n on and is investigating health insurance for patient.\n Action:\n Pt seems more down today, restless this am. Offered ativan to pt which\n she agreed to. Family/friends in to visit, then pt. slept well.\n Response:\n SW assisting with obtaining health insurance. More rest after ativan.\n Plan:\n Follow up with SW. Offer ativan for sleep, also give 2 tylenol before\n sleep to prevent hip pain.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. Lungs with diminished breath sounds in bases. Sats > 97% on 4L\n NP.\n Action:\n IABP weaned from down to 1:2 . Started on captopril 3.125 tid. O2\n weaned down to 2L NP.\n Response:\n pt asymptomatic and MVO2 improved with IABP1:1 to 1:2. Fall in filling\n pressures, MAP and MVO2 after captopril. CO remains with CI:\n . Though pressures falling after captopril, u/o picked up 100-160\n cc/hour. Last lasix . Of note, the MAP from the central lumen of\n the IABP measures ~ 10-15 mm hg above the Fiberoptic MAP. FOB\n transducer zero\nd at time of placement, console reads FOB status\n okay. Consulted with rep from Arrow\n10-15 mm Hg difference between\n these MAP\ns is acceptable, with FOB MAP being more accurate than\n central lumen. Team aware, and will manage patient according to FOB\n MAP trend. Echo done today. Heparin gtt @ 1200 units per hour with\n therapeutic PTT X2. L groin (PA cath) with slight ooze, no hematoma.\n Site cleansed and dressing changed. CSM to feet normal.\n Plan:\n Monitor for CP. Monitor for bleeding at IABP and PA cath site.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer. Given Tylenol 650 mg po for c/o\n hip pain with relief. All access sites clean, without signs of\n infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424248, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she presented to the OSH. EKG there revealed Ant/Lat STE. She was\n transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. LM-nl, Lcx w mild dz, 50% mid RCA. Peak CPK: 6300, Troponin:\n 8.4.\n Pt tx CCU for further management s/p .\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking.\n Action:\n Medication teaching done on ASA, captopril and plavix. Reinforced\n efforts to stop smoking. HCP paper work signed by pt and placed in\n chart.\n Response:\n Understands purpose of medications, continues to express desire to quit\n smoking.\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n craving. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down. SW spoke with pt\n on and is investigating health insurance for patient.\n Action:\n Pt seems more down today, restless this am. Offered ativan to pt which\n she agreed to. Family/friends in to visit, then pt. slept well for the\n next 3 hours.\n Response:\n SW assisting with obtaining health insurance. More restful after\n ativan.\n Plan:\n Follow up with SW. Offer ativan for sleep, also give 2 tylenol before\n sleep to prevent hip pain.\n Myocardial infarction, acute (AMI, , NSTEMI)\n Assessment:\n No CP. Lungs with diminished breath sounds in bases. Sats > 97% on 4L\n NP.\n Action:\n IABP weaned from down to 1:4 . Started on captopril 3.125 tid. O2\n weaned down to 2L NP.\n Response:\n Pt asymptomatic and MVO2 improved with IABP1:1 to 1:2. Fall in filling\n pressures, MAP and MVO2 (64-65%) after captopril. CO / CI 4.5-4.8 /\n 2.6-2.6. IABP reduced to 1:4 @ 1800. Plan to recheck numbers, and\n potentially reduce IABP to 1:8 if CI >2 as per attending. Also, to ^\n captopril dose to 6.25 with next dose. Though pressures falling after\n captopril, u/o picked up to 90-240 cc/hour. Last lasix . Of\n note, the MAP from the central lumen of the IABP measures ~ 10-15 mm hg\n above the Fiberoptic MAP. FOB transducer zero\nd at time of placement,\n console reads\nFOB status okay.\n Consulted with rep from Arrow\n\n mm Hg difference between these MAP\ns is acceptable, with FOB MAP being\n more accurate than central lumen. Team aware, and will manage patient\n according to FOB MAP trend. Echo done today. Heparin gtt @ 1200 units\n per hour with therapeutic PTT X2. L groin (PA cath) with slight ooze,\n CCU intern in to assess--no hematoma. Site cleansed and dressing\n changed. CSM of feet normal. Sats >95% on 2 L NP.\n Plan:\n Monitor for CP. Monitor hemodynamics with IABP wean. Assess for\n bleeding at IABP and PA cath site.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer. Given Tylenol 650 mg po for c/o\n hip pain with relief. All access sites clean, without signs of\n infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424249, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she presented to the OSH. EKG there revealed Ant/Lat STE. She was\n transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. LM-nl, Lcx w mild dz, 50% mid RCA. Peak CPK: 6300, Troponin:\n 8.4.\n Pt tx CCU for further management s/p .\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking.\n Action:\n Medication teaching done on ASA, captopril and plavix. Reinforced\n efforts to stop smoking. HCP paper work signed by pt and placed in\n chart.\n Response:\n Understands purpose of medications, continues to express desire to quit\n smoking.\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n craving. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down. SW spoke with pt\n on and is investigating health insurance for patient.\n Action:\n Pt seems more down today, restless this am. Offered ativan to pt which\n she agreed to. Family/friends in to visit, then pt. slept well for the\n next 3 hours.\n Response:\n SW assisting with obtaining health insurance. More restful after\n ativan.\n Plan:\n Follow up with SW. Offer ativan for sleep, also give 2 tylenol before\n sleep to prevent hip pain.\n Myocardial infarction, acute (AMI, STEMII)\n Assessment:\n MI with large CPK/troponin bump, remains IABP dependent. No further\n CP. Lungs with diminished breath sounds in bases. Sats > 97% on 4L\n NP.\n Action:\n IABP weaned down to 1:4 . Started on captopril 3.125 tid. O2 weaned\n down to 2L NP.\n Response:\n Pt asymptomatic and MVO2 improved with IABP1:1 to 1:2. Fall in filling\n pressures, MAP and MVO2 (64-65%) after captopril. CO / CI 4.5-4.8 /\n 2.6-2.6. IABP reduced to 1:4 @ 1800. Plan to recheck numbers, and\n potentially reduce IABP to 1:8 if CI >2 as per attending. Also, to ^\n captopril dose to 6.25 with next dose. Though pressures falling after\n captopril, u/o picked up to 90-240 cc/hour. Last lasix . Of\n note, the MAP from the central lumen of the IABP measures ~ 10-15 mm hg\n above the Fiberoptic MAP. FOB transducer zero\nd at time of placement,\n console reads\nFOB status okay.\n Consulted with rep from Arrow\n\n mm Hg difference between these MAP\ns is acceptable, with FOB MAP being\n more accurate than central lumen. Team aware, and will manage patient\n according to FOB MAP trend. Echo done today. Heparin gtt @ 1200 units\n per hour with therapeutic PTT X2. L groin (PA cath) with slight ooze,\n CCU intern in to assess--no hematoma. Site cleansed and dressing\n changed. CSM of feet normal. Sats >95% on 2 L NP.\n Plan:\n Monitor for CP. Monitor hemodynamics with IABP wean. Please check\n MVO2 and lytes @ . Assess for bleeding at IABP and PA cath site.\n Feve\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer. Given Tylenol 650 mg po for c/o\n hip pain with relief. All access sites clean, without signs of\n infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Nursing", "chartdate": "2131-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424408, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she presented to the OSH. EKG there revealed Ant/Lat STE. She was\n transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. LM-nl, Lcx w mild dz, 50% mid RCA. Peak CPK: 6300, Troponin:\n 8.4.\n Pt tx CCU for further management s/p .\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking.\n Action:\n Medication teaching done on ASA, captopril and plavix. Reinforced\n efforts to stop smoking. HCP paper work signed by pt and placed in\n chart.\n Response:\n Understands purpose of medications, continues to express desire to quit\n smoking.\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n craving. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down. SW spoke with pt\n on and is investigating health insurance for patient.\n Action:\n Pt seems more down today, restless this am. Offered ativan to pt which\n she agreed to. Family/friends in to visit, then pt. slept well for the\n next 3 hours.\n Response:\n SW assisting with obtaining health insurance. More restful after\n ativan.\n Plan:\n Follow up with SW. Offer ativan for sleep, also give 2 tylenol before\n sleep to prevent hip pain.\n Myocardial infarction, acute (AMI, STEMII)\n Assessment:\n MI with large CPK/troponin bump, remains IABP dependent. No further\n CP. Lungs with diminished breath sounds in bases. Sats > 97% on 4L\n NP.\n Action:\n IABP weaned down to 1:4 . Started on captopril 3.125 tid. O2 weaned\n down to 2L NP.\n Response:\n Pt asymptomatic and MVO2 improved with IABP1:1 to 1:2. Fall in filling\n pressures, MAP and MVO2 (64-65%) after captopril. CO / CI 4.5-4.8 /\n 2.6-2.6. IABP reduced to 1:4 @ 1800. Plan to recheck numbers, and\n potentially reduce IABP to 1:8 if CI >2 as per attending. Also, to ^\n captopril dose to 6.25 with next dose. Though pressures falling after\n captopril, u/o picked up to 90-240 cc/hour. Last lasix . Of\n note, the MAP from the central lumen of the IABP measures ~ 10-15 mm hg\n above the Fiberoptic MAP. FOB transducer zero\nd at time of placement,\n console reads\nFOB status okay.\n Consulted with rep from Arrow\n\n mm Hg difference between these MAP\ns is acceptable, with FOB MAP being\n more accurate than central lumen. Team aware, and will manage patient\n according to FOB MAP trend. Echo done today. Heparin gtt @ 1200 units\n per hour with therapeutic PTT X2. L groin (PA cath) with slight ooze,\n CCU intern in to assess--no hematoma. Site cleansed and dressing\n changed. CSM of feet normal. Sats >95% on 2 L NP.\n Plan:\n Monitor for CP. Monitor hemodynamics with IABP wean. Please check\n MVO2 and lytes @ . Assess for bleeding at IABP and PA cath site.\n Feve\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer. Given Tylenol 650 mg po for c/o\n hip pain with relief. All access sites clean, without signs of\n infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, , NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423754, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF.\n Pt tx CCU for further management s/p stemi.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Rec\nd pt pf on iabp 1:1 via r groin, although c/o nausea. HR 90\ns nsr\n w/ rare pvc\ns, MAP\ns PAD\ns 20-15. Card index improving to O2\n sats down to 92% on 5ln/p, Heparin 500units/hr w/ PTT pnd. LE pulses\n palpable, first troponin post procedure 7.95 (1.25).\n Action:\n Nausea rx w/ zofran, O2 changed to 100% NRB ,\n Response:\n Nausea relieved, O2 sats 97-100%,\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423949, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment)\n Action:\n Discussed risk of smoking with patient. Last smoked , is committed\n to quit smoking. Talked about potential for medications to assist with\n smoking cessation\npatient does not want meds for this. Given smoking\n cessation info. Also contact social worker to assist with stress\n level.\n Response:\n Motivated to quit smoking. Awaiting SW assessment.\n Plan:\n Continue to support pt in efforts to quit smoking. ^ activity level\n when appropriate.\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n CPK\ns have peaked and are now falling, no CP. Lungs with diminished\n breath sounds in bases. Sats >95% on 4L NP, falling to 92% on 2 L NP.\n Action:\n On IABP 1:1, attempted 1:2 for 2 hours. Given 40 mg IV lasix.\n Response:\n pt asymptomatic but MVO2 fell from 65 to 60, CI fell from 2.5 to 2.1\n with IABP wean. Placed back on 1:1. PAD\ns low to mid 20\ns, diuresed\n 1600 cc\ns over 2 hours after lasix with PAD falling to 18-19. Goal PAD\n 15-20. Remains with HR 90\ns Sinus rhythm\nno beta blocker or ace for now\n as per team. Heparin gtt ^ to 1050 units/hour d/t subtherapeutic PTT.\n Recheck: . R and L groin without bleeding, csm to R and L feet\n normal. T max 99.1 po. Blood cultures X2 sent d/t T of 100.5 po last\n evening.\n Plan:\n Monitor for CP. IABP . Monitor augmentation/\n unloading/filling pressures. Recheck PTT. Monitor for bleeding at\n IABP and PA cath site.\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424062, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Anxiety\n Assessment:\n Daughter in with pt and visiting till 10pm. Pt requested total of 2mg\n ativan po for aide in sleeping. She appears calm\n Action:\n Rec\nd total of 2mg ativan,\n Response:\n Was able to sleep in naps\n Plan:\n Cont to provide emotional support, given ativan prn\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr remains elevated in the mid to upper 90\ns low 100\ns sr/st no vea\n noted. K+ 3.1 Maps have remained > 60. Heparin conts at\n 1200units/hr. L and R groins have remained d/I with distal pulses\n palpable. IABP has remained on 1:1 with recent CO/CI 5.2/2.8 (MV sat\n 68%). At approx 5am IABP console approx 10-15pts lower than\n monitor. Cables switched which showed that monitor is correct\n .\n Action:\n Rec\nd total of 60meq iv kcl for low k+\n Response:\n Awaiting am labs to evaluate K+ level\n Plan:\n ? attempt to wean IABP again today. ? start ace prior to wean or beta\n blocker, cont to follow groin/heparin level.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Conts to have low grade temp\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-10-08 00:00:00.000", "description": "CCU resident progress note", "row_id": 423926, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:30 PM\n IABP\n PA CATHETER - START 12:30 PM\n EKG - At 01:00 PM\n CXR raised question of IABP placement, but correct positioning verified\n by attending.\n S: Feeling better. No CP, SOB, had mild back pain that resolved with\n APAP and hasn\nt returned.\n Tele: rare PVCs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 01:30 PM\n Heparin Sodium - 01:20 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 06:15 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: 37.6\nC (99.7\n HR: 95 (84 - 100) bpm\n BP: 113/54(84) {105/53-130/59}\n RR: 22 (7 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n PAP: (35 mmHg) / (26 mmHg)\n CO/CI (Fick): (4.9 L/min) / (2.7 L/min/m2)\n SvO2: 73%\n Mixed Venous O2% Sat: 67 - 76\n Total In:\n 1,990 mL\n 330 mL\n PO:\n 150 mL\n 150 mL\n TF:\n IVF:\n 1,840 mL\n 180 mL\n Blood products:\n Total out:\n 2,039 mL\n 330 mL\n Urine:\n 2,039 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -49 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: 4L Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n GEN: NAD\n P: CTAB, no w/r/r\n CV: RRR, no m/r/g\n Abd: S NT ND\n Ext: WWP, 2+ pulse on left, + on right.\n Neruo: Normal strength and sensation in distal lower extremities\n Labs / Radiology\n Type:Mix\n O2Sat: 65\n \n 06:38a\n Type:Mix\n Hgb:11.9\n CalcHCT:36\n O2Sat: 77\n \n 06:03a\n _______________________________________________________________________\n Source: Line-swan\n 140\n [image002.gif]\n 106\n [image002.gif]\n 18\n [image004.gif]\n 123\n AGap=11\n [image005.gif]\n 3.7\n [image002.gif]\n 27\n [image002.gif]\n 0.8\n [image007.gif]\n CK: 3749\n MB: 196\n MBI: 5.2\n Trop-T: 7.28\n Comments:\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 8.1 Mg: 2.2 P: 2.6 D\n Source: Line-swan\n 85\n 12.1\n [image007.gif]\n 11.8\n [image004.gif]\n 159\n [image008.gif]\n [image004.gif]\n 34.6\n [image007.gif]\n Source: \n PT: 14.3\n PTT: 51.2\n INR: 1.2\n 01:27 PM\n 05:51 PM\n 12:25 AM\n 12:30 AM\n WBC\n 13.8\n 15.3\n Hct\n 39.3\n 38.1\n 38\n Plt\n 192\n 177\n Cr\n 1.0\n 0.8\n TropT\n 7.95\n 8.41\n 7.29\n Glucose\n 139\n 116\n Other labs: PT / PTT / INR:13.9/42.4/1.2, CK / CKMB /\n Troponin-T:4512/341/7.29, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 56 y/o female with hyperlipidemia who presented\n with chest pain and found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Cardiac index of 1.3 indicative of cardiogenic shock\n and requiring IABP. She had a large anterior infarction, now s/p\n stenting of proximal and distal LAD.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 15-20, will diurese as necessary. 40 mg\n IV lasix to start.\n - Goal cardiac index , goal to space pump frequency. Curently at\n 1:1. Will attempt to wean to 1:2 today\n - heparin gtt while on IABP\n - ASA , statin 80 mg, plavix\n - Given cardiogenic shock, no beta-blocker, ACE, or spironolactone for\n now\n - montior pump waveforms\n - TEE tomorrow.\n - Follow cardiac enzymes to peak\n - Daily EKGs, CXRs\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: NPO for now\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -Bowel regimen\n CODE: full\n DISPO: CCU\n 1. IV access: Peripheral line Order date: @ 1259\n 11. Lorazepam 0.5-1 mg IV Q4H:PRN Anxiety\n Hold for sedation or RR < 12. Order date: @ 1340\n 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain Order date: @ 2120\n 12. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses Order date: \n @ 1757\n 3. Aspirin EC 325 mg PO DAILY Order date: @ 1259\n 13. Morphine Sulfate 1-2 mg IV Q4H:PRN Pain\n Please hold for sedation or RR < 12. Order date: @ 1259\n 4. Atorvastatin 80 mg PO DAILY Order date: @ 1020\n 14. Ondansetron 4 mg IV Q8H:PRN Nausea Order date: @ 1259\n 5. Atropine Sulfate 0.5 mg IV X1:PRN symptomatic bradycardia &\n hypotension\n repeat up to 2 mg total (including Atropine during procedure)\n Order date: @ 1259\n 15. Pantoprazole 40 mg PO Q24H Order date: @ 1020\n 6. Clopidogrel 75 mg PO DAILY\n for the recommended duration Order date: @ 1259\n 16. Potassium Chloride 40 mEq / 100 ml SW IV ONCE Duration: 1 Doses\n Order date: @ 2120\n 7. Docusate Sodium 100 mg PO BID:PRN Order date: @ 0620\n 17. Potassium Chloride 40 mEq / 100 ml SW IV ONCE Duration: 1 Doses\n Order date: @ 1020\n 8. Furosemide 40 mg IV ONCE Duration: 1 Doses Order date: @ 1011\n 18. Senna 1 TAB PO BID:PRN Order date: @ 0620\n 9. Heparin IV per Weight-Based Dosing Guidelines\n Order date: @ 1259\n 19. 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: @ 1259\n 10. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1223\n" }, { "category": "Physician ", "chartdate": "2131-10-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424358, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 09:06 AM\n Uptitrated Captopril\n IABP to 1:2 in PM, 1:4 in evening, 1:8 at 3AM. After 1hr at 1:8, PAD\n 15, ScO2 61, CI 2.7 (4AM).\n S: mild constipation, no CP, SOB, back pain, other complaints\n Tele: Rare PVCs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:24 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: 36.8\nC (98.3\n HR: 89 (89 - 106) bpm\n BP: 91/41(70) {91/41(57) - 113/67(90)} mmHg\n RR: 22 (17 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n PAP: (30 mmHg) / (12 mmHg)\n CO/CI (Fick): (5.2 L/min) / (2.8 L/min/m2)\n SvO2: 61%\n Mixed Venous O2% Sat: 61 - 71\n Total In:\n 2,104 mL\n 773 mL\n PO:\n 1,200 mL\n 440 mL\n TF:\n IVF:\n 904 mL\n 333 mL\n Blood products:\n Total out:\n 2,255 mL\n 640 mL\n Urine:\n 2,255 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n GEN: NAD\n P: CTAB, no w/r/r\n CV: RRR, no m/r/g\n Abd: S NT, slightly distended\n Ext: WWP, 2+ pulse on left, 1+ on right.\n Neruo: Normal strength and sensation in distal lower extremities\n Labs / Radiology\n 114 K/uL\n 10.3 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33\n 13.1 K/uL\n [image002.jpg]\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n 02:23 PM\n 08:00 PM\n 11:36 PM\n 04:27 AM\n 04:45 AM\n WBC\n 13.5\n 13.1\n Hct\n 36\n 36\n 36\n 33.0\n 34\n 34\n 34\n 30.2\n 33\n Plt\n 114\n 114\n Cr\n 0.8\n 0.9\n 0.7\n Glucose\n 189\n 138\n 129\n Other labs: PT / PTT / INR:15.1/110.5/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Cardiac index of 1.3 indicative of cardiogenic shock\n and requiring IABP. She had a large anterior infarction, now s/p\n stenting of proximal and distal LAD. Currently not IABP dependent.\n Echo with LV dysfunction, will likely need anticoagulation given apical\n thrombus risk.\n - Will D/C IABP today\n - D/C Swan this afternoon if stable\n - heparin gtt while on IABP, will hold prior to d/c. Coumadin tonight\n - ASA , statin 80 mg, plavix , Captopril\n - will add beta-blocker and spironolactone as tolerated by BP.\n - Daily\n EKGs\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE\n Counseled by SW about smoking cessation.\n .\n THROMBOCYTOPENIA\n Platlets stable. Likely IABP.\n .\n HYPERLIPIDEMIA - continue statin\n .\n FEN: NPO for now\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -Bowel regimen\n CODE: full\n DISPO: CCU\n 1. IV access: Temporary central access (ICU) Location: Right Femoral,\n Date inserted: Order date: @ 1422\n 12. Lorazepam 0.5-1 mg PO/IV Q4H:PRN\n hold for sedation or RR <8 Order date: @ 2206\n 2. IV access: Peripheral line Order date: @ 1259\n 13. Magnesium Sulfate 2 gm IV ONCE Mg-1.8 Duration: 1 Doses Order date:\n @ 0623\n 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain Order date: @ 2120\n 14. Morphine Sulfate 1-2 mg IV Q4H:PRN Pain\n Please hold for sedation or RR < 12. Order date: @ 1259\n 4. Aspirin EC 325 mg PO DAILY Order date: @ 1259\n 15. Ondansetron 4 mg IV Q8H:PRN Nausea Order date: @ 1259\n 5. Atorvastatin 80 mg PO DAILY Order date: @ 1020\n 16. Pantoprazole 40 mg PO Q24H Order date: @ 1020\n 6. Atropine Sulfate 0.5 mg IV X1:PRN symptomatic bradycardia &\n hypotension\n repeat up to 2 mg total (including Atropine during procedure)\n Order date: @ 1259\n 17. Potassium Chloride 20 mEq / 50 ml SW IV ONCE K-3.9 Duration: 1\n Doses Order date: @ 0623\n 7. Captopril 12.5 mg PO TID Start: next dose\n Hold for MAP < 65 Order date: @ 2335\n 18. Senna 1 TAB PO BID:PRN Order date: @ 0620\n 8. Clopidogrel 75 mg PO DAILY\n for the recommended duration Order date: @ 1259\n 19. 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: @ 1422\n 9. Docusate Sodium 100 mg PO BID:PRN Order date: @ 0620\n 20. 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: @ 1259\n 10. Heparin (IABP) 3 ml/hr IV INFUSION\n For Intra-aortic Ballon Pump Administration Only Order date: @\n 1346\n 21. Warfarin 5 mg PO DAILY16 Order date: @ 1017\n 11. Heparin IV per Weight-Based Dosing Guidelines\n Order date: @ 1259\n" }, { "category": "Nursing", "chartdate": "2131-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424298, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n Remains CP free, awaiting wean and d/c of IABP as of . Doing well\n with ativan for restlessness r/t proglonged strict bedrest.\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-10-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424326, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 09:06 AM\n Started on Captopril 3.125 earlier in day- increased at qhs to 6.25\n tid.\n IABP to 1:2 in PM and 1:4 in evening. Weaned to IABP x 1 hour to 1:8\n with hemodynamics unchanged.\n Response:\n Pt remains hemodynamically stable, asymptomatic. CI/CO\n -2.4-2.7/4.5-4.9. MAPS-63-74, MVo2-61-66%. Systolic unloading 3-14 pts.\n PTT rechecked this AM on current Heparin dose. Groins/pulses stable.\n Good uo- 80-100cc/hour. Extremities warm. Denies pain of SOB.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 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 06:39 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 (99.1\n HR: 98 (89 - 106) bpm\n BP:\n Unass Sys 84 (73-90)\n Dia 95 (73-101)\n Asst sys 72 (60-83)\n PAEDP 35 (44-57)\n RR: 17 (17 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n PAP: 33/15 (21)\n PAMm: 15-26\n CO/CI (Fick): (4.5-5.8) 4.9 L/min\n CI: (2.4-3.1) 2.7 L/min/m2\n SvO2: 61%\n Mixed Venous O2% Sat: 61 - 71\n Total In:\n 2,104 mL\n 378 mL\n PO:\n 1,200 mL\n 200 mL\n TF:\n IVF:\n 904 mL\n 178 mL\n Blood products:\n Total out:\n 2,255 mL\n 520 mL\n Urine:\n 2,255 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n -142 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 114 K/uL\n 10.3 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33\n 13.1 K/uL\n [image002.jpg]\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n 02:23 PM\n 08:00 PM\n 11:36 PM\n 04:27 AM\n 04:45 AM\n WBC\n 13.5\n 13.1\n Hct\n 36\n 36\n 36\n 33.0\n 34\n 34\n 34\n 30.2\n 33\n Plt\n 114\n 114\n Cr\n 0.8\n 0.9\n 0.7\n Glucose\n 189\n 138\n 129\n Other labs: PT / PTT / INR:15.1/110.5/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n The left atrium is mildly dilated. No atrial septal defect is seen by\n 2D or color Doppler. Left ventricular wall thicknesses and cavity size\n are normal. There is mild regional left ventricular systolic\n dysfunction with severe hypokinesis of the anterior wall, anterior\n septum and apex and mild hypokinesis of the anterolateral wall. Overall\n left ventricular systolic function is mild to moderately depressed\n (LVEF= 40 %). Tissue Doppler imaging suggests an increased left\n ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and\n tissue velocity imaging are consistent with Grade II (moderate) LV\n diastolic dysfunction. The remaining left ventricular segments contract\n normally. Right ventricular chamber size and free wall motion are\n normal. The number of aortic valve leaflets cannot be determined. The\n aortic valve leaflets are mildly thickened. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. There is an anterior space which most likely\n represents a fat pad.\n IMPRESSION: Mild to moderate regional left ventricular dysfunction c/w\n coronary artery disease (LAD territory). Moderate diastolic dysfunction\n with elevated filling pressures.\n Assessment and Plan\n Increase Captopril 12.5\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:30 PM\n PA Catheter - 12:30 PM\n 20 Gauge - 12:30 PM\n 18 Gauge - 12:30 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": "2131-10-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424328, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 09:06 AM\n Started on Captopril 3.125 earlier in day- increased at qhs to 6.25\n tid.\n IABP to 1:2 in PM and 1:4 in evening. Weaned to IABP x 1 hour to 1:8\n with hemodynamics unchanged (PAD 15, SvO2 61%, CI 2.7 @ 4AM)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 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 06:39 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 (99.1\n HR: 98 (89 - 106) bpm\n BP:\n Unass Sys 84 (73-90)\n Dia 95 (73-101)\n Asst sys 72 (60-83)\n PAEDP 35 (44-57)\n RR: 17 (17 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n PAP: 33/15 (21)\n PAMm: 15-26\n CO/CI (Fick): (4.5-5.8) 4.9 L/min\n CI: (2.4-3.1) 2.7 L/min/m2\n SvO2: 61%\n Mixed Venous O2% Sat: 61 - 71\n Total In:\n 2,104 mL\n 378 mL\n PO:\n 1,200 mL\n 200 mL\n TF:\n IVF:\n 904 mL\n 178 mL\n Blood products:\n Total out:\n 2,255 mL\n 520 mL\n Urine:\n 2,255 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -151 mL\n -142 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 114 K/uL\n 10.3 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33\n 13.1 K/uL\n [image002.jpg]\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n 02:23 PM\n 08:00 PM\n 11:36 PM\n 04:27 AM\n 04:45 AM\n WBC\n 13.5\n 13.1\n Hct\n 36\n 36\n 36\n 33.0\n 34\n 34\n 34\n 30.2\n 33\n Plt\n 114\n 114\n Cr\n 0.8\n 0.9\n 0.7\n Glucose\n 189\n 138\n 129\n Other labs: PT / PTT / INR:15.1/110.5/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n The left atrium is mildly dilated. No atrial septal defect is seen by\n 2D or color Doppler. Left ventricular wall thicknesses and cavity size\n are normal. There is mild regional left ventricular systolic\n dysfunction with severe hypokinesis of the anterior wall, anterior\n septum and apex and mild hypokinesis of the anterolateral wall. Overall\n left ventricular systolic function is mild to moderately depressed\n (LVEF= 40 %). Tissue Doppler imaging suggests an increased left\n ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and\n tissue velocity imaging are consistent with Grade II (moderate) LV\n diastolic dysfunction. The remaining left ventricular segments contract\n normally. Right ventricular chamber size and free wall motion are\n normal. The number of aortic valve leaflets cannot be determined. The\n aortic valve leaflets are mildly thickened. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. There is an anterior space which most likely\n represents a fat pad.\n IMPRESSION: Mild to moderate regional left ventricular dysfunction c/w\n coronary artery disease (LAD territory). Moderate diastolic dysfunction\n with elevated filling pressures.\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Large anterior MI now s/p stenting of LAD. Cardiac\n index initially 1.3 indicative of cardiogenic shock and requiring\n IABP. Currently HD stable, even\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 15-20, Goal cardiac index \n - Was tried on 1:2 with drop in SVO2 and MAP, so restarted 1:1, will\n try again today given improved PAD.\n - Pump waveforms consistent with good timing, will continue to montior\n - heparin gtt while on IABP\n - ASA, statin, plavix\n - Will try low dose ACEi for remodeling, still holding BB\n - TEE today\n - Cardiac enzymes trending down\n - Daily EKGs, CXR for placement of IABP\n .\n IABP console discrepancy\n confirmed to be more accurate on telemetry\n monitor. Will discuss\n .\n THROMBOCYTOPENIA: Plt 190 on admission, now 114 in 1.5days.\n - Likely due to mechanical destruction, as presentation too early\n for HIT.\n - Will monitor\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: Cardiac\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -PPI\n CODE: full\n DISPO: CCU\n Increase Captopril 12.5\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:30 PM\n PA Catheter - 12:30 PM\n 20 Gauge - 12:30 PM\n 18 Gauge - 12:30 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": "2131-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424421, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she presented to the OSH. EKG there revealed Ant/Lat STE. She was\n transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. LM-nl, Lcx w mild dz, 50% mid RCA. Peak CPK: 6300, Troponin:\n 8.4.\n Pt tx CCU for further management s/p .\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking. Per pt, she and her\n friend were going to quit for the New Year.\n Action:\n Cardiac teaching including MI, stent and medications. Smoking\n cessation information reviewed.\n Response:\n Pt states that she is going to change her ways, as of now. .\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n craving. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down.\n Action:\n Appropriate grieving, as pt is weepy today. Ativan given for IABP\n removal. Friend in to visit, who is very supportive of pt. SW\n in to visit, but pt was sleeping at that time\n Response:\n Appreciative of support\n Plan:\n Follow up with SW tomorrow. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMII)\n Assessment:\n MI with large CPK/troponin bump without further CP. Lungs with\n diminished breath sounds in bases to clear. Sats >94% as pt self dc\n her O2. CO/CI per . Bilat groins d/I post sheath removal\n Action:\n Rec\nd first dose of Captopril 12.5mg this am. Heparin dc\nd at 1100\n for IABP dc\nd at 1330 . Swan dc\nd at\n Response:\n Tolerated IABP removal w/ subsequent CI,\n Plan:\n Monitor for CP, hemodynamics pre and post captopril administration and\n titrate as able. Monitor groins for change, increase activity as\n tolerated.\n Fever\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer without encouragement. IV\n re-sited per policy. All access sites clean, without signs of\n infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, , NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424480, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n Remains CP free, awaiting wean and d/c of IABP as of . Doing well\n with ativan for restlessness r/t proglonged strict bedrest.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Increased activity evening- OOB to\n Chair x 1 hour after dangling. Groins and peripheral pulses have\n remained stable/ intact, WNL.\n evening-one episode of CP 10p in setting of sitting up in chair-\n EKG without acute ischemic changes- pain d/c after 2 sl TNG. Pt anxious\n w pain and continues on Ativan PRN and currently asleep, comfortable\n and CP free.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt admitted to CCU for acute STEMI c/b CHF/low CI and treated with\n stent LAD/IABP/diuretics.\n Action:\n Pt remains on captopril 12.5 tid, no addition of B Blocker this shift.\n Pt on coumadin load, off heparin gtt. Bilateral groin sites remain D/I\n s/p sheath removal bilaterally 2p-6p ( IABP and PA LINE).\n Increased activity to dangle/OOB to -Chair x 1 hour. One episode of\n CP while up in chair and of note, after taking in ice chips/cold drink-\n ? epigastric/SS. Denies SOB or increased pain with taking deep breaths.\n (-) EKG- tx with sl TNG x 2 and pain free.\n Response:\n Pt pain free after sl TNG. Remains hemodynamically stable other than\n single episode of CP on evening. Tolerating captopril., adequate O2\n sats on 4l np.\n Plan:\n Continue to maximize rate/pressure product- consider low dose B blocker\n this am. AM CXR- consider gentle diuresis if pt ^ CHF =watch pulmonary\n and renal status closely. Very very gradual activity progression as pt\n had little tolerance evening for dangle/OOB after several days\n bedrest/large AMI. c/o to floor once medically appropriate.\n Anxiety\n Assessment:\n PT s/p large AMI and prolonged bedrest with some mild\n anxiety/restlessness.\n Action:\n Pt given qhs 1 mg ativan after episode of CP that made her more anxious\n overall, as well as much teaching and emotional support.\n Response:\n Pt currently sleeping, comfortable and free of anxiety.\n Plan:\n Continue teaching/ support. Continue to monitor for increased anxiety-\n medication as needed.\n Encourage pt to tell staff when increase in anxiety is occurring as\n well as any CP or SOB or symptoms overall.\n" }, { "category": "Nursing", "chartdate": "2131-10-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424664, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n Remains CP free, awaiting wean and d/c of IABP as of . Doing well\n with ativan for restlessness r/t proglonged strict bedrest.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Increased activity evening- OOB to\n Chair x 1 hour after dangling. Groins and peripheral pulses have\n remained stable/ intact, WNL.\n evening-one episode of CP 10p in setting of sitting up in chair-\n EKG without acute ischemic changes- pain d/c after 2 sl TNG. Pt anxious\n w pain and continues on Ativan PRN and currently asleep, comfortable\n and CP free.\n episode of c.p. at 14:00, received ntg sl x2, relieved;\n anti-hypertensives adjusted, lopressor increased, lisinopril added\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt hypotensive 7-11p portion of this 12 hour shift (this charting\n nurse took over care of pt at 11p) (see below for further discussion of\n hypotension)\n T 100.0 (o) at 23:30, pt noted to have\nsweated\n at approx 02:00;\n Action:\n Received Tylenol 650 mg po\n Response:\n T decreased to 98.6 (o) 2 hours later;\n Plan:\n Continue to follow for s/s infection d/t invasive procedures\n Anxiety\n Assessment:\n Pt requested ativan at hs\n Action:\n Pt seemed relaxed, seemed to doze off easily; administration of ativan\n delayed then decided against d/t pt\ns hypetension during the eveing,\n and pt seemed to be sleeping restfully during the night\n Response:\n Pt\ns b/p returned to low acceptable; pt sleeping during this night\n Plan:\n Ativan is ordered prn for this pt for symptomatic anxiety\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt had adjustment of some cardiac meds\nlopressor increased from 12.5 to\n 25 mg pot id, pt ordered for additional 12.5 yest afternoon, then\n received 25 mg dose at 18:00; also received 1^st dose of newly ordered\n lisinopril yest afternoon;\n Pt also s/p lasix 20 mg at 12noon, however is felt pt is also\n auto-diuresing; fluid net balance 1200 cc\ns for previous 24 hours,\n reportedly goal was ccs;\n Pt hypotensive 7p-11p portion of shift\n Action:\n Pt given another 250 cc NS IVF bolus over 60 minutes; 12a lopressor\n held d/t sbp 86;\n Response:\n Pt\ns b/p returned to acceptable range at very early a.m. checks \n (sbp 99 at 03:00)\n Plan:\n Cont to follow exam, b/p\n Lisinopril rescheduled to not be given 8a w/ lopressor, but at 12p\n instead;\n Check results a.m. labs\n" }, { "category": "Nursing", "chartdate": "2131-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424475, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-10-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424709, "text": "TITLE:\n Chief Complaint:\n STEMI\n 24 Hour Events:\n Patient\ns SBPs have been in 70-90s. Received 250cc NS x 3 in past 18\n hrs. Added BB and switched from captopril to lisinopril.\n Temp 100.0 at MN, received APAP x 1, resolved.\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Other medications:\n ASA 325mg\n Plavix 75mg\n Lipitor 80mg\n Pantoprazole 40mg\n Lisinopril 10mg\n Coumadin 5mg\n Lopressor 25mg TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37\nC (98.6\n HR: 86 (79 - 109) bpm\n BP: 99/58(68) {74/43(50) - 124/6,756(92)} mmHg\n RR: 20 (10 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n Total In:\n 922 mL\n 590 mL\n PO:\n 672 mL\n 90 mL\n TF:\n IVF:\n 250 mL\n 500 mL\n Blood products:\n Total out:\n 2,115 mL\n 460 mL\n Urine:\n 2,115 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,193 mL\n 130 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN NAD, appears more comfortable\n HEENT MMM, JVP 8cm\n CV: No new murmurs or thrills, RRR\n PULM: Crackles at bases\n ABD soft, NT, ND, +BS, no HSM\n EXT no edema, WWP\n NEURO A+O x 3\n SKIN small left groin hematoma, no bruits or tenderness\n Labs / Radiology\n 168 K/uL\n 10.1 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 23 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.2 %\n 10.2 K/uL\n [image002.jpg]\n 05:04 AM\n 02:23 PM\n 08:00 PM\n 11:36 PM\n 04:27 AM\n 04:45 AM\n 03:36 PM\n 06:20 AM\n 08:34 PM\n 03:08 AM\n WBC\n 13.5\n 13.1\n 9.1\n 10.2\n Hct\n 33.0\n 34\n 34\n 34\n 30.2\n 33\n 33\n 30.6\n 29.2\n Plt\n 114\n 114\n 143\n 168\n Cr\n 0.9\n 0.7\n 0.8\n 1.0\n 0.9\n TropT\n 6.29\n Glucose\n 138\n 129\n 115\n 120\n 116\n Other labs: PT / PTT / INR:14.2/23.5/1.2, CK / CKMB /\n Troponin-T:167/4/6.29, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with HL and tobacco abuse pw chest pain and found to have\n a STEMI to an occluded LAD.\n CARDIOGENIC SHOCK: s/p large anterior infarct and stenting of LAD,\n initially cardiac index of 1.3 indicative of cardiogenic shock and\n requiring IABP.\n - IABP and swan removed yesterday after showing no more dependence (CI\n 3, MV0@ 65% and PAD 15 prior to removal)\n - Continues to do well without mechanical support\n BP and HR stable.\n - Coumadin started for low flow in area of akinetic/hypokinetic apex\n - ASA , statin 80 mg, plavix , Captopril\n - Will change captopril to lisinopril\n - will add beta-blocker today, and still hold off on spironolactone\n - Daily EKGs\n CHF: pt fluid overloaded, will give low dose lasix and monitor closely\n CHEST PAIN: similar in quality to prior CP but in setting of PO intake.\n - DDx: esophageal spasm, inflammatory, ACS.\n - ? recheck CEs.\n RHYTHM: NSR currently. Monitor on telemetry.\n TOBACCO ABUSE\n Counseled by SW about smoking cessation.\n THROMBOCYTOPENIA\n Platlets stable. Likely IABP.\n HYPERLIPIDEMIA - continue statin at increased dose\n FEN: Cardiac, No IVF, lytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DV: Warfarin, PPI\n CODE: full\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:53 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": "2131-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424588, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424653, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n Remains CP free, awaiting wean and d/c of IABP as of . Doing well\n with ativan for restlessness r/t proglonged strict bedrest.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Increased activity evening- OOB to\n Chair x 1 hour after dangling. Groins and peripheral pulses have\n remained stable/ intact, WNL.\n evening-one episode of CP 10p in setting of sitting up in chair-\n EKG without acute ischemic changes- pain d/c after 2 sl TNG. Pt anxious\n w pain and continues on Ativan PRN and currently asleep, comfortable\n and CP free.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 98-110 sr no vea, bp stable, oob to chair w/ one assist, episode\n 5/10 chest pain., given 20 mg iv lasix. Pt calm and relaxed today\n requiring no ativan.\n Action:\n Started on lopressor 12.5 mg, captopril changed to lisinopril. Ekg done\n w/ith chest pain, no changes, described as mid sternal radiating to\n left arm and jaw.\n Response:\n hr to mid 90\ns w/ lopressor, chest pain relieved w/ 2 sl ntg. Excellent\n response to iv lasix. Educational material re: recovering from heart\n attack given to patient.\n Plan:\n Monitor hr, ? ^ lopressor, monitor for pain, follow u/o, ^ activity as\n tolerated. Reinforce post MI education w/ pt. Pt\ns daughter is RN on\n 3.\n ------ Protected Section ------\n Nursing Progress Note 1900-2130\n No change in plan of care since prior note. Patient denied c/o pain or\n discomfort. Labs colleceted at (electrolytes and BUN/Cr), results\n pending. Please see metavision for complete ROS. Patient requesting\n ativan for sleep aid at 1030 pm.\n ------ Protected Section Addendum Entered By: , RN\n on: 21:26 ------\n" }, { "category": "General", "chartdate": "2131-10-11 00:00:00.000", "description": "Generic Note", "row_id": 424585, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n IABP, swan and A line removed without complications\n Chest pain at 9:40pm (, SBP 120, HR 100s) pt sitting up, eating ice\n chips, relieved with NTG x 2. EKG unchanged.\n ROS: Denies any current CP, SOB, lightheadedness/dizziness, back pain.\n Was out of bed to chair yesterday.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.9\nC (98.4\n HR: 91 (88 - 107) bpm\n BP: 93/55(64) {87/43(58) - 126/67(77)} mmHg\n RR: 24 (15 - 33) insp/min\n SpO2: 95% NC\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78 kg (admission): 80 kg\n Height: 63 Inch\n Last in early afternoon:\n PAP: (39 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.4 L/min) / (3 L/min/m2)\n SvO2: 65%\n Mixed Venous O2% Sat: 65 - 65\n Total In:\n 1,696 mL\n PO:\n 1,280 mL\n TF:\n IVF:\n 416 mL\n Blood products:\n Total out:\n 1,885 mL\n 560 mL\n Urine:\n 1,885 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -189 mL\n -560 mL\n Physical Examination\n GEN NAD, appears more comfortable\n HEENT MMM, JVP 8cm\n CV: No new murmurs or thrills, RRR\n PULM: Crackles at bases\n ABD soft, NT, ND, +BS, no HSM\n EXT no edema, WWP\n NEURO A+O x 3\n SKIN small left groin hematoma, no bruits or tenderness\n Labs / Radiology\n 143 K/uL\n 10.5\n 115 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 17 mg/dL\n 101 mEq/L\n 135 mEq/L\n 30.9\n 9.1\n [image002.jpg]\n Assessment and Plan\n 56 y/o female with HL and tobacco abuse pw chest pain and found to have\n a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: s/p large anterior infarct and stenting of LAD,\n initially cardiac index of 1.3 indicative of cardiogenic shock and\n requiring IABP.\n - IABP and swan removed yesterday after showing no more dependence (CI\n 3, MV0@ 65% and PAD 15 prior to removal)\n - Continues to do well without mechanical support\n BP and HR stable.\n - Coumadin started for low flow in area of akinetic/hypokinetic apex\n - ASA , statin 80 mg, plavix , Captopril\n - Will change captopril to lisinopril\n - will add beta-blocker today, and still hold off on spironolactone\n - Daily EKGs\n CHF: pt fluid overloaded, will give low dose lasix and monitor closely\n .\n CHEST PAIN: similar in quality to prior CP but in setting of PO intake.\n - DDx: esophageal spasm, inflammatory, ACS.\n - ? recheck CEs.\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE\n Counseled by SW about smoking cessation.\n .\n THROMBOCYTOPENIA\n Platlets stable. Likely IABP.\n .\n HYPERLIPIDEMIA - continue statin at increased dose\n .\n FEN: Cardiac, No IVF, lytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DV: Warfarin, PPI\n CODE: full\n DISPO: CCU\n Active Medications , A\n 1. Warfarin 5 mg PO DAILY16\n 8. Morphine Sulfate 1-2 mg IV Q4H:PRN Pain\n 2. Nitroglycerin SL 0.3 mg SL PRN CP\n 9. Docusate Sodium 100 mg PO BID\n 3. Aspirin EC 325 mg PO DAILY\n 10. Ondansetron 4 mg IV Q8H:PRN Nausea\n 4. Atorvastatin 80 mg PO DAILY\n 11. Pantoprazole 40 mg PO Q24H\n 5. Captopril 12.5 mg PO TID\n 12. Senna 1 TAB PO BID:PRN\n 6. Clopidogrel 75 mg PO DAILY\n 13. Acetaminophen 325-650 mg PO Q6H:PRN Pain\n 7. Lorazepam 0.5-1 mg PO/IV Q4HPRN\n 14. Aluminum-Magnesium OH.-Simethicone 15-30mL prn\n" }, { "category": "Nursing", "chartdate": "2131-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424592, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n Remains CP free, awaiting wean and d/c of IABP as of . Doing well\n with ativan for restlessness r/t proglonged strict bedrest.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Increased activity evening- OOB to\n Chair x 1 hour after dangling. Groins and peripheral pulses have\n remained stable/ intact, WNL.\n evening-one episode of CP 10p in setting of sitting up in chair-\n EKG without acute ischemic changes- pain d/c after 2 sl TNG. Pt anxious\n w pain and continues on Ativan PRN and currently asleep, comfortable\n and CP free.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 98-110 sr no vea, bp stable, oob to chair w/ one assist, episode\n 5/10 chest pain., given 20 mg iv lasix. Pt calm and relaxed today\n requiring no ativan.\n Action:\n Started on lopressor 12.5 mg, captopril changed to lisinopril. Ekg done\n w/ith chest pain, no changes, described as mid sternal radiating to\n left arm and jaw.\n Response:\n hr to mid 90\ns w/ lopressor, chest pain relieved w/ 2 sl ntg. Excellent\n response to iv lasix. Educational material re: recovering from heart\n attack given to patient.\n Plan:\n Monitor hr, ? ^ lopressor, monitor for pain, follow u/o, ^ activity as\n tolerated. Reinforce post MI education w/ pt. Pt\ns daughter is RN on\n 3.\n" }, { "category": "Nursing", "chartdate": "2131-10-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 424823, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH.\n EKG there revealed Ant/ STE. Troponin 1.25. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP\n r groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi. Pt maintained on IABP, CP\n free since admission- asymptomatic. Weaned down to 1:4 by and\n started on low dose Captopril. Multiple hemodyamics calculated and pt\n has remained stable with CI- 2.4-2.8.\n - Pt weaned and d/c IABP from rt groin and PA line d/c from left\n groin with adequate CO/CI. Groins and peripheral pulses have remained\n stable/ intact, WNL. evening and evening-one episode of CP\n \\in setting of sitting up in chair- EKG without acute ischemic changes-\n pain d/c after 2 sl TNG. Pt anxious w pain and continues on Ativan PRN.\n Pt has had some intermittent hypotension w/ medication increases- \n lopressor was increased to 25mg tid and lisinopril was added. Most\n recent episode 5am requiring 250cc ivf bolus, Lopressor had been\n decreased to 12.5mg tid, but again increased to 25mg tid w/ low\n hold parameters. Lasix 20mg po added to regime.\n Increased activity evening- OOB to Chair x 1 hour after\n dangling. able to dangle and assist w/ am care, f/b oob to\n chair.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n STEMI\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 80 kg\n Daily weight:\n 78 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: inc chol\n Surgery / Procedure and date: Cath - 2 stents to LAD\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:95\n D:61\n Temperature:\n 99.4\n Arterial BP:\n S:99\n D:58\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 97 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 890 mL\n 24h total out:\n 970 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 03:08 AM\n Potassium:\n 4.4 mEq/L\n 03:08 AM\n Chloride:\n 104 mEq/L\n 03:08 AM\n CO2:\n 23 mEq/L\n 03:08 AM\n BUN:\n 23 mg/dL\n 03:08 AM\n Creatinine:\n 0.9 mg/dL\n 03:08 AM\n Glucose:\n 116 mg/dL\n 03:08 AM\n Hematocrit:\n 29.2 %\n 03:08 AM\n Finger Stick Glucose:\n 167\n 12:00 PM\n Valuables / Signature\n Patient valuables: No valuables w/ pt, with the exception of a cell\n phone\n Other valuables:\n Clothes: Sent home with: daughter on admission\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 622\n Transferred to: 306\n Date & time of Transfer: 1700\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T current 99.4\n Action:\n Received Tylenol 650 mg po over night\n Response:\n normothermic\n Plan:\n Continue to follow for s/s infection d/t invasive procedures\n Anxiety/ Knowledge Deficit\n Assessment:\n Pt acknowledged that her life is stressful and needs to make some\n changes. Pt unable to identify meds and their actions\n Action:\n Medication review w/ each administration\n Response:\n Pt able to repeat information\n Plan:\n Continue teaching as this will decrease anxiety\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n BP continues 88-95/\n Action:\n Lopressor dose held at 0800 and administered at 1000 as bp slightly\n higher. Lopressor dose this am 12.5 f/b 25mg this afternoon at 1600.\n Response:\n Pt\ns b/p 90\n Plan:\n Close hemodynamic monitoring. Stagger meds as necessary\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423798, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid\n Pt tx CCU for further management s/p stemi.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies cp/sob. Hr 94-97 remains in nsr occasional pvc noted. K+ 3.5.\n ptt subtherapeutic @ 42.4 IABP @ 1:1 unassisted sbp 89-108, \n pressures 96-106. ck\ns 4512 (6300), MB 7.29 (7.95) MAP\nS 66-78. PAD\n 23-25 (GOAL 20-25) CO 4.9 CI 2.7 W MVS 73%.\n Action:\n Repleted k+ w 40meq iv . heparin bolus per order 1300u/ rate ^ to\n 900u/hr\n Response:\n No further cp, adequqte bp,augmentation, stable post procedure\n Plan:\n Con\nt to cycle ck\ns, hemodynamics, recheck am ptt and titrate per\n protocol.\n Anxiety\n Assessment:\n Restless, difficulty sleeping. Many stressors in life. Recent job loss,\n divorce, new diagnosis/hospitalization\n Action:\n Ativan 1mg iv @ hs,support\n Response:\n slept\n Plan:\n Con\nt ativan. Support, consider social service consult\n" }, { "category": "Nursing", "chartdate": "2131-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423717, "text": "HPI: 56 y/o female with a h/o hyperlipidemia who presented to an OSH on\n the AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon, she again developed the\n same SSCP, this time radiating to her left arm, associated with nausea\n and vomiting. Denied associated SOB. Pain persisted until Sunday AM\n when she finally presented to the OSH. EKG there revealed STE in V2-V4.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\n IABP immediately placed r groin TO prox LAD w/ much clot.\n Stent x2 were placed. Swan placed l groin. Post intervention cardiac\n index 1.7. Case c/b hypotensive rx with IVF.\n Pt tx CCU for further management s/p stemi.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Rec\nd pt pf on iabp 1:1 via r groin, although c/o nausea. HR 90\ns nsr\n w/ rare pvc\ns, MAP\ns PAD\ns 20-15. O2 sats down to 92% on 5ln/p,\n Heparin 500units/hr w/ PTT pnd. LE pulses palpable, first troponin\n post procedure 7.95 (1.25).\n Action:\n Nausea rx w/ zofran, O2 changed to 100% NRB ,\n Response:\n Nausea relieved, O2 sats 97-100%,\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423793, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid\n Pt tx CCU for further management s/p stemi.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-10-08 00:00:00.000", "description": "CCU resident", "row_id": 423858, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:30 PM\n IABP\n PA CATHETER - START 12:30 PM\n EKG - At 01:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 01:30 PM\n Heparin Sodium - 01:20 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 06:15 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: 37.6\nC (99.7\n HR: 95 (84 - 100) bpm\n BP: 113/54(84) {0/0(0) - 130/60(93)} mmHg\n RR: 22 (7 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n PAP: (35 mmHg) / (26 mmHg)\n CO/CI (Fick): (4.9 L/min) / (2.7 L/min/m2)\n SvO2: 73%\n Mixed Venous O2% Sat: 67 - 76\n Total In:\n 1,990 mL\n 330 mL\n PO:\n 150 mL\n 150 mL\n TF:\n IVF:\n 1,840 mL\n 180 mL\n Blood products:\n Total out:\n 2,039 mL\n 330 mL\n Urine:\n 2,039 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -49 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 177 K/uL\n 13.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 19 mg/dL\n 104 mEq/L\n 140 mEq/L\n 38\n 15.3 K/uL\n [image002.jpg]\n 01:27 PM\n 05:51 PM\n 12:25 AM\n 12:30 AM\n WBC\n 13.8\n 15.3\n Hct\n 39.3\n 38.1\n 38\n Plt\n 192\n 177\n Cr\n 1.0\n 0.8\n TropT\n 7.95\n 8.41\n 7.29\n Glucose\n 139\n 116\n Other labs: PT / PTT / INR:13.9/42.4/1.2, CK / CKMB /\n Troponin-T:4512/341/7.29, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 56 y/o female with hyperlipidemia who presented\n with chest pain and found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Cardiac index of 1.3 indicative of cardiogenic shock\n and requiring IABP. She had a large anterior infarction, now s/p\n stenting of proximal and distal LAD.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 20-25, will hydrate or diurese as\n necessary\n - Goal cardiac index , goal to space pump frequency. Curently at\n 1:1.\n - heparin gtt while on IABP\n - ASA, no beta-blocker for now while on pump, statin, plavix\n - montior pump waveforms\n - TEE tomorrow.\n - Follow cardiac enzymes to peak\n - Daily EKGs\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: NPO for now\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -Bowel regimen\n CODE: full\n DISPO: CCU\n TITLE:\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423966, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Action:\n Discussed risk of smoking with patient. Last smoked , is committed\n to quit smoking. Talked about potential for medications to assist with\n smoking cessation\npatient does not want meds for this. Given smoking\n cessation info. Also contact social worker to assist with stress\n level. Pt given info re: HCP. dose ^ to 80 mg qd.\n Response:\n Motivated to quit smoking. Seems a bit overwhelmed with level of\n information.\n Plan:\n Continue to support pt in efforts to quit smoking. ^ activity level\n when appropriate. Cardiac rehab upon discharge. To complete HCP when\n daughter in to visit. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down.\n Action:\n SW consult. Offered ativan on several occasions, patient refused.\n Response:\n SW assisting with obtaining health insurance, pt seemed relieved by\n this. Pt napping during shift.\n Plan:\n Follow up with SW. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n CPK\ns have peaked and are now falling, no CP. Lungs with diminished\n breath sounds in bases. Sats >95% on 4L NP, falling to 92% on 2 L NP.\n Action:\n On IABP 1:1, attempted 1:2 for 2 hours. Given 40 mg IV lasix.\n Response:\n pt asymptomatic but MVO2 fell from 65 to 60, CI fell from 2.5 to 2.1\n with IABP wean. Placed back on 1:1 with MV O2 ^ 68%.. PAD\ns low to\n mid 20\ns, diuresed 1600 cc\ns over 2 hours after lasix with PAD falling\n to 18-22. Goal PAD 15-20. Remains with HR 90\ns-100 NSR/ST\nno beta\n blocker or ace for now as per team. Heparin gtt ^ to 1050 units/hour\n d/t sub-therapeutic PTT. Recheck: . R and L groin without\n bleeding, csm to R and L feet normal.\n Plan:\n Monitor for CP. IABP . Monitor augmentation/\n unloading/filling pressures. Recheck PTT. Monitor for bleeding at\n IABP and PA cath site.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.4 po. WBC 12.1. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine sent. Pt with dry cough. Using incentive\n spirometer. Given Tylenol 650 mg po. All access clean, without signs\n of infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423968, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Action:\n Discussed risk of smoking with patient. Last smoked , is committed\n to quit smoking. Talked about potential for medications to assist with\n smoking cessation\npatient does not want meds for this. Given smoking\n cessation info. Also contact social worker to assist with stress\n level. Pt given info re: HCP. dose ^ to 80 mg qd.\n Response:\n Motivated to quit smoking. Seems a bit overwhelmed with level of\n information.\n Plan:\n Continue to support pt in efforts to quit smoking. ^ activity level\n when appropriate. Cardiac rehab upon discharge. To complete HCP when\n daughter in to visit. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down.\n Action:\n SW consult. Offered ativan on several occasions, patient refused.\n Response:\n SW assisting with obtaining health insurance, pt seemed relieved by\n this. Pt napping during shift.\n Plan:\n Follow up with SW. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n CPK\ns have peaked and are now falling, no CP. Lungs with diminished\n breath sounds in bases. Sats >95% on 4L NP, falling to 92% on 2 L NP.\n Action:\n On IABP 1:1, attempted 1:2 for 2 hours. Given 40 mg IV lasix.\n Response:\n pt asymptomatic but MVO2 fell from 65 to 60, CI fell from 2.5 to 2.1\n with IABP wean. Placed back on 1:1 with MV O2 ^ 68%.. PAD\ns low to\n mid 20\ns, diuresed 1600 cc\ns over 2 hours after lasix (-1L since mn),\n with PAD falling to 18-22. Goal PAD 15-20. Remains with HR 90\ns-100\n NSR/ST\nno beta blocker or ace for now as per team. Heparin gtt ^ to\n 1050 units/hour d/t sub-therapeutic PTT, ^ 1200 units/hour (with 1300\n unit bolus). R and L groin without bleeding, csm to R and L feet\n normal.\n Plan:\n Monitor for CP. IABP on 1:1 . Monitor augmentation/ unloading/filling\n pressures. Recheck PTT @ 2300. Monitor for bleeding at IABP and PA\n cath site. Lytes PND.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.4 po. WBC 12.1. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine sent. Pt with dry cough. Using incentive\n spirometer. Given Tylenol 650 mg po. All access clean, without signs\n of infection. Routine MRSA swab obtained.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423962, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter as HCP, no paper work done.\n Action:\n Discussed risk of smoking with patient. Last smoked , is committed\n to quit smoking. Talked about potential for medications to assist with\n smoking cessation\npatient does not want meds for this. Given smoking\n cessation info. Also contact social worker to assist with stress\n level. Pt given info re: HCP.\n Response:\n Motivated to quit smoking.\n Plan:\n Continue to support pt in efforts to quit smoking. ^ activity level\n when appropriate. Cardiac rehab upon discharge. To complete HCP when\n daughter in to visit.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down.\n Action:\n SW consult. Offered ativan on several occasions, patient refused.\n Response:\n SW assisting with obtaining health insurance, pt seemed relieved by\n this. Pt napping during shift.\n Plan:\n Follow up with SW. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n CPK\ns have peaked and are now falling, no CP. Lungs with diminished\n breath sounds in bases. Sats >95% on 4L NP, falling to 92% on 2 L NP.\n Action:\n On IABP 1:1, attempted 1:2 for 2 hours. Given 40 mg IV lasix.\n Response:\n pt asymptomatic but MVO2 fell from 65 to 60, CI fell from 2.5 to 2.1\n with IABP wean. Placed back on 1:1 with MV O2 ^ 68%.. PAD\ns low to\n mid 20\ns, diuresed 1600 cc\ns over 2 hours after lasix with PAD falling\n to 18-22. Goal PAD 15-20. Remains with HR 90\ns-100 NSR/ST\nno beta\n blocker or ace for now as per team. Heparin gtt ^ to 1050 units/hour\n d/t sub-therapeutic PTT. Recheck: . R and L groin without\n bleeding, csm to R and L feet normal.\n Plan:\n Monitor for CP. IABP . Monitor augmentation/\n unloading/filling pressures. Recheck PTT. Monitor for bleeding at\n IABP and PA cath site.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.4 po. WBC 12.1. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine sent. Pt with dry cough. Using incentive\n spirometer. Given Tylenol 650 mg po. All access clean, without signs\n of infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424064, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Anxiety\n Assessment:\n Daughter in with pt and visiting till 10pm. Pt requested total of 2mg\n ativan po for aide in sleeping. She appears calm\n Action:\n Rec\nd total of 2mg ativan,\n Response:\n Was able to sleep in naps\n Plan:\n Cont to provide emotional support, given ativan prn\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr remains elevated in the mid to upper 90\ns low 100\ns sr/st no vea\n noted. K+ 3.1 Maps have remained > 60. Heparin conts at\n 1200units/hr. L and R groins have remained d/I with distal pulses\n palpable. IABP has remained on 1:1 with recent CO/CI 5.2/2.8 (MV sat\n 68%). At approx 5am IABP console approx 10-15pts lower than\n monitor. Cables switched which showed that monitor is correct\n .\n Action:\n Rec\nd total of 60meq iv kcl for low k+\n Response:\n Awaiting am labs to evaluate K+ level\n Plan:\n ? attempt to wean IABP again today. ? start ace prior to wean or beta\n blocker, cont to follow groin/heparin level.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Conts to have low grade temp, cultures remain pnd\n Action:\n Following temps\n Response:\n Plan:\n Cont to follow temps/culture results\n" }, { "category": "Physician ", "chartdate": "2131-10-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 423736, "text": "Chief Complaint: Chest pain, STEMI\n HPI: 56 y/o female with a h/o hyperlipidemia who presented to an OSH on\n the AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n Friday AM at work. The pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon, she again developed the\n same SSCP, this time radiating to her left arm, associated with nausea.\n Denied associated SOB. Pain persisted until Sunday AM when she finally\n presented to the OSH. EKG there revealed STE in V2-V4. She was given SL\n nitro x 3, Lopressor 5 mg IV x 3, ASA, Plavix loaded, heparin bolus +\n gtt, and integrillin bolus + drip. She was transferred to \n urgently for cardiac catheterization. EKG at Hospital ED\n revealed a NSR, rate 86, STE in V2-6. STD in III. Normal axis.\n In the cath lab, she was found to have a totally occluded proximal LAD.\n She had two stents placed to her LAD. She then became hypotensive and\n was resuscitated with IVF. An IABP was placed along with a femoral\n Swan.\n Upon arrival to the CCU, she was hemodynamically stable and chest pain\n free. She had no complaints.\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were negative.\n Cardiac review of systems is notable for chest pain, dyspnea on\n exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Patient admitted from: Cath lab, transfer from OSH\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 500 units/hour\n Other ICU medications:\n Plavix 75 mg PO daily\n Lipitor 20 mg PO daily\n ASA 325 mg PO daily\n Other medications:\n Zofran PRN\n Morphine PRN\n Ativan PRN\n Past medical history:\n Family history:\n Social History:\n Hyperlipidemia\n Depression\n Tobacco Abuse\n Mother with MI at age 74. Sister and brother with .\n Occupation: Secretary\n Drugs: None\n Tobacco: cigarettes daily for the past 25 years\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\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 Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 94 (84 - 97) bpm\n BP: 107/58(68) {0/0(0) - 116/58(85)} mmHg\n RR: 20 (20 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n PAP: (43 mmHg) / (23 mmHg)\n CO/CI (Fick): (4 L/min) / (2.2 L/min/m2)\n SvO2: 67%\n Mixed Venous O2% Sat: 67 - 67\n Total In:\n 1,475 mL\n PO:\n TF:\n IVF:\n 1,475 mL\n Blood products:\n Total out:\n 0 mL\n 1,625 mL\n Urine:\n 1,625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -150 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Bases, No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 192 K/uL\n 13.2\n 139 mg/dL\n 1.0 mg/dL\n 19 mg/dL\n 26 mEq/L\n 99 mEq/L\n 4.2 mEq/L\n 136 mEq/L\n 39.3 %\n 13.8 K/uL\n [image002.jpg]\n \n 2:33 A11/9/ 01:27 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 13.8\n Hct\n 39.3\n Plt\n 192\n Cr\n 1.0\n TropT\n 7.95\n Glucose\n 139\n Other labs: PT / PTT / INR:13.6/34.3/1.2, CK / CKMB /\n Troponin-T:6137//7.95, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n CARDIOGENIC SHOCK: Cardiac index of 1.3 indicative of cardiogenic\n shock, requiring IABP. She had a large anterior infarction, now s/p\n stenting of proximal and distal LAD.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 20-25, will hydrate or diurese as\n necessary\n - Goal cardiac index , goal to space pump frequency. Currently at\n 1:1.\n - heparin gtt while on IABP\n - ASA, no beta-blocker for now while on pump, statin, plavix\n - monitor pump waveforms\n - TEE tomorrow.\n - Follow cardiac enzymes to peak\n - Daily EKGs\n RHYTHM: NSR currently. Monitor on telemetry.\n TOBACCO ABUSE - Counseled about smoking cessation.\n HYPERLIPIDEMIA - continue statin.\n TRANSAMINITIS - Likely from cardiogenic shock. Will continue to\n monitor LFTs for trend.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n Arterial Line - 12:30 PM\n PA Catheter - 12:30 PM\n 20 Gauge - 12:30 PM\n 18 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423808, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid\n Pt tx CCU for further management s/p stemi.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies cp/sob. Hr 94-97 remains in nsr occasional pvc noted. K+ 3.5.\n ptt subtherapeutic @ 42.4 IABP @ 1:1 unassisted sbp 89-108, \n pressures 96-106. ck\ns 4512 (6300), MB 7.29 (7.95) MAP\nS 66-78. PAD\n 23-25 (GOAL 20-25) CO 4.9 CI 2.7 W MVS 73%.\n Action:\n Repleted k+ w 40meq iv . heparin bolus per order 1300u/ rate ^ to\n 900u/hr\n Response:\n No further cp, adequqte bp,augmentation, stable post procedure\n Plan:\n Con\nt to cycle ck\ns, hemodynamics, recheck am ptt and titrate per\n protocol.\n Anxiety\n Assessment:\n Restless, difficulty sleeping. Many stressors in life. Recent job loss,\n divorce, new diagnosis/hospitalization\n Action:\n Ativan 1mg iv @ hs,support\n Response:\n slept\n Plan:\n Con\nt ativan. Support, consider social service consult\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o lower back and hip pain associated w BR.\n Action:\n Repositioned frequently, Tylenol 650mg po for pain\n Response:\n Pain free after receiving Tylenol/backrub\n Plan:\n Assess for further pain. Offer Tylenol, position chg\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424184, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50%\n mid. Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking.\n Action:\n Medication teaching done on ASA, captopril and plavix. Reinforced\n efforts to stop smoking. HCP paper work signed by pt and placed in\n chart.\n Response:\n Understands purpose of medications.\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n cravings. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down. SW spoke with pt\n on and is investigating health insurance for patient.\n Action:\n Pt seems more down today, restless this am. Offered ativan to pt which\n she agreed to. Family/friends in to visit, then pt. slept.\n Response:\n SW assisting with obtaining health insurance. More rest after ativan.\n Plan:\n Follow up with SW. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. Lungs with diminished breath sounds in bases. Sats > 97% on 4L\n NP.\n Action:\n IABP weaned from down to 1:2 . Started on captopril 3.125 tid. O2\n weaned down to 2L NP.\n Response:\n pt asymptomatic and MVO2 improved with IABP1:1 to 1:2. Fall in filling\n pressures, MAP and MVO2 after captopril. CO remains with CI:\n Echo done today. Heparin gtt @ 1200 units per hour with therapeutic\n PTT X2. L groin (PA cath) with slight ooze, no hematoma. Site\n cleansed and dressing changed. CSM to feet normal.\n Plan:\n Monitor for CP. Monitor for bleeding at IABP and PA cath site.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer. Given Tylenol 650 mg po for c/o\n hip pain. All access sites clean, without signs of infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Physician ", "chartdate": "2131-10-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424131, "text": "TITLE:\n Chief Complaint:\n 56 y/o female with HL, tobacco abuse, p/w anterior STEMI (now s/p stent\n to LAD) c/b cardiogenic shock requiring IABP.\n 24 Hour Events:\n BCx, UCx sent for temp of 100.4\n Did not tolerate trial of 1:2 IABP\n ROS: No chest or back pain, no SOB.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 AM\n Heparin Sodium - 05:00 PM\n Other medications:\n Flowsheet Data as of 06:25 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: 37.9\nC (100.3\n HR: 95 (87 - 102) bpm\n BP: 109/55(83) {84/37(50) - 119/55(84)} mmHg\n RR: 24 (16 - 31) insp/min\n SpO2: 98% on NC\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.3 kg (admission): 80 kg\n Height: 63 Inch\n CVP: 12 (12 - 12)mmHg\n PAP: (32 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.2 L/min) / (2.8 L/min/m2)\n SvO2: 68%\n Mixed Venous O2% Sat: 60 - 77\n MAP: 60s-80s\n PAD: 16-22\n SYS:70\n :98\n DIA 30\n Total In:\n 2,408 mL\n 475 mL\n PO:\n 1,530 mL\n 120 mL\n TF:\n IVF:\n 878 mL\n 355 mL\n Blood products:\n Total out:\n 3,635 mL\n 525 mL\n Urine:\n 3,635 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,227 mL\n -50 mL\n Physical Examination\n General Appearance: Well nourished, No acute distress, overweight\n Eyes / Conjunctiva: PERRL, MMM\n Head, Ears, Nose, Throat: no JVD\n Cardiovascular: RRR, no MRG with pump turned off\n Respiratory / Chest: CTA B\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-distended\n Groin: No tenderness, no hematomas, no bruits\n Peripheral Vascular: warm well perfused, DP pulses present\n Neurologic: Alert and Oriented x 3\n Labs / Radiology\n 114 K/uL\n 11.4 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33.0 %\n 13.5 K/uL\n [image002.jpg]\n 01:27 PM\n 05:51 PM\n 12:25 AM\n 12:30 AM\n 06:03 AM\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n WBC\n 13.8\n 15.3\n 12.1\n 13.5\n Hct\n 39.3\n 38.1\n 38\n 34.6\n 36\n 36\n 36\n 33.0\n Plt\n 192\n 177\n 159\n 114\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.9\n TropT\n 7.95\n 8.41\n 7.29\n 7.28\n Glucose\n 139\n 116\n 123\n 189\n 138\n Other labs: PT / PTT / INR:14.9/90.8/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Large anterior MI now s/p stenting of LAD. Cardiac\n index initially 1.3 indicative of cardiogenic shock and requiring\n IABP.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 15-20, Goal cardiac index \n - Was tried on 1:2 with drop in SVO2 and MAP, so restarted 1:1, will\n try again today given improved PAD.\n - Pump waveforms consistent with good timing, will continue to montior\n - heparin gtt while on IABP\n - no beta-blocker, spironolactone, or ACE for now while on pump\n - ASA, statin, plavix\n - TEE today\n - Cardiac enzymes trending down\n - Daily EKGs, CXR for placement of IABP\n .\n IABP console discrepancy\n confirmed to be more accurate on telemetry\n monitor. Will discuss\n .\n THROMBOCYTOPENIA: Plt 190 on admission, now 114 in 1.5days.\n - Likely due to mechanical destruction, as presentation too early\n for HIT.\n - Will monitor\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: NPO for now\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -PPI\n CODE: full\n DISPO: CCU\n" }, { "category": "Physician ", "chartdate": "2131-10-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424134, "text": "TITLE:\n Chief Complaint:\n 56 y/o female with HL, tobacco abuse, p/w anterior STEMI (now s/p stent\n to LAD) c/b cardiogenic shock requiring IABP.\n 24 Hour Events:\n BCx, UCx sent for temp of 100.4\n Did not tolerate trial of 1:2 IABP\n ROS: No chest or back pain, no SOB.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 AM\n Heparin Sodium - 05:00 PM\n Other medications:\n Flowsheet Data as of 06:25 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: 37.9\nC (100.3\n HR: 95 (87 - 102) bpm\n BP: 109/55(83) {84/37(50) - 119/55(84)} mmHg\n RR: 24 (16 - 31) insp/min\n SpO2: 98% on NC\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.3 kg (admission): 80 kg\n Height: 63 Inch\n CVP: 12 (12 - 12)mmHg\n PAP: (32 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.2 L/min) / (2.8 L/min/m2)\n SvO2: 68%\n Mixed Venous O2% Sat: 60 - 77\n MAP: 60s-80s\n PAD: 16-22\n Unassisted diastole: 40s-50s\n Augmented diastole: 90s-100s\n Unassisted systole: 80s-90s\n Augmented systole: 60s-80s\n Total In:\n 2,408 mL\n 475 mL\n PO:\n 1,530 mL\n 120 mL\n TF:\n IVF:\n 878 mL\n 355 mL\n Blood products:\n Total out:\n 3,635 mL\n 525 mL\n Urine:\n 3,635 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,227 mL\n -50 mL\n Physical Examination\n General Appearance: Well nourished, No acute distress, overweight\n Eyes / Conjunctiva: PERRL, MMM\n Head, Ears, Nose, Throat: no JVD\n Cardiovascular: RRR, no MRG with pump turned off\n Respiratory / Chest: CTA B\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-distended\n Groin: No tenderness, no hematomas, no bruits\n Peripheral Vascular: warm well perfused, DP pulses present\n Neurologic: Alert and Oriented x 3\n Labs / Radiology\n 114 K/uL\n 11.4 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33.0 %\n 13.5 K/uL\n [image002.jpg]\n 01:27 PM\n 05:51 PM\n 12:25 AM\n 12:30 AM\n 06:03 AM\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n WBC\n 13.8\n 15.3\n 12.1\n 13.5\n Hct\n 39.3\n 38.1\n 38\n 34.6\n 36\n 36\n 36\n 33.0\n Plt\n 192\n 177\n 159\n 114\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.9\n TropT\n 7.95\n 8.41\n 7.29\n 7.28\n Glucose\n 139\n 116\n 123\n 189\n 138\n Other labs: PT / PTT / INR:14.9/90.8/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Large anterior MI now s/p stenting of LAD. Cardiac\n index initially 1.3 indicative of cardiogenic shock and requiring\n IABP.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 15-20, Goal cardiac index \n - Was tried on 1:2 with drop in SVO2 and MAP, so restarted 1:1, will\n try again today given improved PAD.\n - Pump waveforms consistent with good timing, will continue to montior\n - heparin gtt while on IABP\n - ASA, statin, plavix\n - Will try low dose ACEi for remodeling, still holding BB\n - TEE today\n - Cardiac enzymes trending down\n - Daily EKGs, CXR for placement of IABP\n .\n IABP console discrepancy\n confirmed to be more accurate on telemetry\n monitor. Will discuss\n .\n THROMBOCYTOPENIA: Plt 190 on admission, now 114 in 1.5days.\n - Likely due to mechanical destruction, as presentation too early\n for HIT.\n - Will monitor\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: Cardiac\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -PPI\n CODE: full\n DISPO: CCU\n" }, { "category": "Physician ", "chartdate": "2131-10-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424106, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:00 AM\n NASAL SWAB - At 08:53 AM\n BLOOD CULTURED - At 12:00 PM\n BLOOD CULTURED - At 12:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 AM\n Heparin Sodium - 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 06:25 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: 37.9\nC (100.3\n HR: 95 (87 - 102) bpm\n BP: 109/55(83) {84/37(50) - 119/55(84)} mmHg\n RR: 24 (16 - 31) insp/min\n SpO2: 98% on NC\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.3 kg (admission): 80 kg\n Height: 63 Inch\n CVP: 12 (12 - 12)mmHg\n PAP: (32 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.2 L/min) / (2.8 L/min/m2)\n SvO2: 68%\n Mixed Venous O2% Sat: 60 - 77\n MAP: 60s-80s\n PAD: 16-22\n Total In:\n 2,408 mL\n 475 mL\n PO:\n 1,530 mL\n 120 mL\n TF:\n IVF:\n 878 mL\n 355 mL\n Blood products:\n Total out:\n 3,635 mL\n 525 mL\n Urine:\n 3,635 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,227 mL\n -50 mL\n Physical Examination\n General Appearance: Well nourished, No acute distress, overweight\n Eyes / Conjunctiva: PERRL, MMM\n Head, Ears, Nose, Throat: no JVD\n Cardiovascular: unable to assess with pump\n Peripheral Vascular: strong distal pulses\n Respiratory / Chest: CTA B\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-distended\n Neurologic: Alert and Oriented x 3\n Labs / Radiology\n 114 K/uL\n 11.4 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33.0 %\n 13.5 K/uL\n [image002.jpg]\n 01:27 PM\n 05:51 PM\n 12:25 AM\n 12:30 AM\n 06:03 AM\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n WBC\n 13.8\n 15.3\n 12.1\n 13.5\n Hct\n 39.3\n 38.1\n 38\n 34.6\n 36\n 36\n 36\n 33.0\n Plt\n 192\n 177\n 159\n 114\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.9\n TropT\n 7.95\n 8.41\n 7.29\n 7.28\n Glucose\n 139\n 116\n 123\n 189\n 138\n Other labs: PT / PTT / INR:14.9/90.8/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Large anterior MI now s/p stenting of LAD. Cardiac\n index initially 1.3 indicative of cardiogenic shock and requiring\n IABP.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 15-20, Goal cardiac index \n - Was tried on 1:2 with drop in SVO2 and MAP, so restarted 1:1, will\n try again today given improved PAD.\n - Pump waveforms consistent with good timing, will continue to montior\n - heparin gtt while on IABP\n - no beta-blocker, spironolactone, or ACE for now while on pump\n - ASA, statin, plavix\n - TEE today\n - Cardiac enzymes trending down\n - Daily EKGs, CXR for placement of IABP\n .\n IABP console discrepancy\n confirmed to be more accurate on telemetry\n monitor. Will discuss\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: NPO for now\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -PPI\n CODE: full\n DISPO: Cardiology floor service for now\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424107, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Anxiety\n Assessment:\n Daughter in with pt and visiting till 10pm. Pt requested total of 2mg\n ativan po for aide in sleeping. She appears calm\n Action:\n Rec\nd total of 2mg ativan,\n Response:\n Was able to sleep in naps\n Plan:\n Cont to provide emotional support, given ativan prn\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr remains elevated in the mid to upper 90\ns low 100\ns sr/st no vea\n noted. K+ 3.1 Maps have remained > 60. Heparin conts at\n 1200units/hr. L and R groins have remained d/I with distal pulses\n palpable. IABP has remained on 1:1 with recent CO/CI 5.2/2.8 (MV sat\n 68%). At approx 5am IABP console approx 10-15pts lower than\n monitor. Cables switched which showed that monitor is correct\n .\n Action:\n Rec\nd total of 60meq iv kcl for low k+\n Response:\n Awaiting am labs to evaluate K+ level\n Plan:\n ? attempt to wean IABP again today. ? start ace prior to wean or beta\n blocker, cont to follow groin/heparin level.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Conts to have low grade temp, cultures remain pnd\n Action:\n Following temps\n Response:\n Plan:\n Cont to follow temps/culture results\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424108, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE.\n Troponin 1.25. She was given SL nitro x 3, Lopressor 5 mg IV x 3, ASA,\n Plavix loaded, heparin bolus + gtt, and integrillin bolus + drip. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP r\n groin and Swan placed l groin. Post intervention cardiac index 1.7.\n Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50% mid.\n Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Action:\n Discussed risk of smoking with patient. Last smoked , is committed\n to quit smoking. Talked about potential for medications to assist with\n smoking cessation\npatient does not want meds for this. Given smoking\n cessation info. Also contact social worker to assist with stress\n level. Pt given info re: HCP. dose ^ to 80 mg qd.\n Response:\n Motivated to quit smoking. Seems a bit overwhelmed with level of\n information.\n Plan:\n Continue to support pt in efforts to quit smoking. ^ activity level\n when appropriate. Cardiac rehab upon discharge. To complete HCP when\n daughter in to visit. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down.\n Action:\n SW consult. Offered ativan on several occasions, patient refused.\n Response:\n SW assisting with obtaining health insurance, pt seemed relieved by\n this. Pt napping during shift.\n Plan:\n Follow up with SW. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n CPK\ns have peaked and are now falling, no CP. Lungs with diminished\n breath sounds in bases. Sats >95% on 4L NP, falling to 92% on 2 L NP.\n Action:\n On IABP 1:1, attempted 1:2 for 2 hours. Given 40 mg IV lasix.\n Response:\n pt asymptomatic but MVO2 fell from 65 to 60, CI fell from 2.5 to 2.1\n with IABP wean. Placed back on 1:1 with MV O2 ^ 68%.. PAD\ns low to\n mid 20\ns, diuresed 1600 cc\ns over 2 hours after lasix (-1L since mn),\n with PAD falling to 18-22. Goal PAD 15-20. Remains with HR 90\ns-100\n NSR/ST\nno beta blocker or ace for now as per team. Heparin gtt ^ to\n 1050 units/hour d/t sub-therapeutic PTT, ^ 1200 units/hour (with 1300\n unit bolus). R and L groin without bleeding, csm to R and L feet\n normal.\n Plan:\n Monitor for CP. IABP on 1:1 . Monitor augmentation/ unloading/filling\n pressures. Recheck PTT @ 2300. Monitor for bleeding at IABP and PA\n cath site. Lytes PND.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.4 po. WBC 12.1. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine sent. Pt with dry cough. Using incentive\n spirometer. Given Tylenol 650 mg po. All access clean, without signs\n of infection. Routine MRSA swab obtained.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Physician ", "chartdate": "2131-10-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 424101, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:00 AM\n NASAL SWAB - At 08:53 AM\n BLOOD CULTURED - At 12:00 PM\n BLOOD CULTURED - At 12:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 AM\n Heparin Sodium - 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 06:25 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: 37.9\nC (100.3\n HR: 95 (87 - 102) bpm\n BP: 109/55(83) {84/37(50) - 119/55(84)} mmHg\n RR: 24 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.3 kg (admission): 80 kg\n Height: 63 Inch\n CVP: 12 (12 - 12)mmHg\n PAP: (32 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.2 L/min) / (2.8 L/min/m2)\n SvO2: 68%\n Mixed Venous O2% Sat: 60 - 77\n Total In:\n 2,408 mL\n 475 mL\n PO:\n 1,530 mL\n 120 mL\n TF:\n IVF:\n 878 mL\n 355 mL\n Blood products:\n Total out:\n 3,635 mL\n 525 mL\n Urine:\n 3,635 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,227 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 114 K/uL\n 11.4 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 136 mEq/L\n 33.0 %\n 13.5 K/uL\n [image002.jpg]\n 01:27 PM\n 05:51 PM\n 12:25 AM\n 12:30 AM\n 06:03 AM\n 06:38 AM\n 07:00 AM\n 03:41 PM\n 03:49 PM\n 05:04 AM\n WBC\n 13.8\n 15.3\n 12.1\n 13.5\n Hct\n 39.3\n 38.1\n 38\n 34.6\n 36\n 36\n 36\n 33.0\n Plt\n 192\n 177\n 159\n 114\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.9\n TropT\n 7.95\n 8.41\n 7.29\n 7.28\n Glucose\n 139\n 116\n 123\n 189\n 138\n Other labs: PT / PTT / INR:14.9/90.8/1.3, CK / CKMB /\n Troponin-T:3749/196/7.28, ALT / AST:113/480, Alk Phos / T Bili:129/0.5,\n Differential-Neuts:86.8 %, Lymph:9.9 %, Mono:3.1 %, Eos:0.1 %,\n Albumin:4.2 g/dL, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 56 y/o female with hyperlipidemia who presented with chest pain and\n found to have a STEMI to an occluded LAD.\n .\n CARDIOGENIC SHOCK: Large anterior MI now s/p stenting of LAD. Cardiac\n index initially 1.3 indicative of cardiogenic shock and requiring\n IABP.\n - Continue IABP, following Q4 PA diastolic pressure and cardiac index\n - Goal PA diastolic pressure 15-20, Goal cardiac index \n - Was tried on 1:2 with drop in SVO2 and MAP, so restarted 1:1, will\n try again today given improved PAD.\n - heparin gtt while on IABP\n - no beta-blocker, spironolactone, or ACE for now while on pump\n - ASA, statin, plavix\n - Pump waveforms consistent with good timing, will continue to montior\n - TEE tomorrow.\n - Cardiac enzymes trending down\n - Daily EKGs, CXR for placement of IABP\n .\n RHYTHM: NSR currently. Monitor on telemetry.\n .\n TOBACCO ABUSE - Council about smoking cessation.\n .\n HYPERLIPIDEMIA - continue statin\n .\n LFT ELEVATION - Likely from cardiogenic shock. Will continue to\n monitor LFTs to trend down.\n .\n FEN: NPO for now\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin gtt.\n -Bowel regimen\n CODE: full\n DISPO: Cardiology floor service for now\n" }, { "category": "Nursing", "chartdate": "2131-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424195, "text": "56 y/o female with a h/o hyperlipidemia who presented to an OSH on the\n AM of with 10/10 substernal and left-sided chest pain,\n radiating down the left arm. Per patient, she noted the onset of SSCP\n on Friday, , however the pain lasted for about an hour and resolved\n without any intervention. Was not associated with any SOB or other\n symptoms. Subsequently, on Saturday afternoon , she again developed\n the same SSCP, this time radiating to her left arm, associated with\n nausea and vomiting. Denied SOB. Pain persisted until Sunday AM when\n she finally presented to the OSH. EKG there revealed Ant/ STE. She\n was transferred to urgently for cardiac catheterization.\n Cath lab\nTO prox LAD w/ much clot. Stent x2 were placed. IABP R\n groin and PA cath placed L groin. Post intervention cardiac index\n 1.7. Case c/b hypotensive rx with IVF. LM-nl,lcx w mild dx, rca 50%\n mid. Peak CPK: 6300 Troponin: 8.4.\n Pt tx CCU for further management s/p stemi.\n Knowledge Deficit\n Assessment:\n CRF: + obesity, smoker, ^ cholesterol, FH (mother died @ 74 with MI\n and CVA), +stress (recent unemployment), sedentary lifestyle. Pt\n designated daughter (RN on 3) as HCP, no paper work done.\n Family supportive of efforts to stop smoking.\n Action:\n Medication teaching done on ASA, captopril and plavix. Reinforced\n efforts to stop smoking. HCP paper work signed by pt and placed in\n chart.\n Response:\n Understands purpose of medications.\n Plan:\n Continue to support pt in efforts to quit smoking, assess for nicotine\n cravings. ^ activity level when appropriate. Cardiac rehab upon\n discharge. Pace teaching re: stent, CAD, diet, activity,\n meds\nbrochures at pt\ns bedside. Continue med teaching with each\n administration.\n Anxiety\n Assessment:\n Stressors: recent unemployment, ? of health insurance. Pt describes\n being very active and doesn\nt like to be tied down. SW spoke with pt\n on and is investigating health insurance for patient.\n Action:\n Pt seems more down today, restless this am. Offered ativan to pt which\n she agreed to. Family/friends in to visit, then pt. slept.\n Response:\n SW assisting with obtaining health insurance. More rest after ativan.\n Plan:\n Follow up with SW. Offer ativan for sleep.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. Lungs with diminished breath sounds in bases. Sats > 97% on 4L\n NP.\n Action:\n IABP weaned from down to 1:2 . Started on captopril 3.125 tid. O2\n weaned down to 2L NP.\n Response:\n pt asymptomatic and MVO2 improved with IABP1:1 to 1:2. Fall in filling\n pressures, MAP and MVO2 after captopril. CO remains with CI:\n . Though pressures falling after captopril, u/o picked up 100-160\n cc/hour. Last lasix . Of note, the MAP from the central lumen of\n the IABP measures ~ 10-15 mm hg above the Fiberoptic MAP. FOB\n transducer zero\nd at time of placement, console reads FOB status\n okay. Consulted with rep from Arrow\n10-15 mm Hg difference between\n these MAP\ns is acceptable, with FOB MAP being more accurate than\n central lumen. Team aware, and will manage patient according to FOB\n MAP trend. Echo done today. Heparin gtt @ 1200 units per hour with\n therapeutic PTT X2. L groin (PA cath) with slight ooze, no hematoma.\n Site cleansed and dressing changed. CSM to feet normal.\n Plan:\n Monitor for CP. Monitor for bleeding at IABP and PA cath site.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 99.9 po. WBC 13. ? infection vs. MI temp.\n Action:\n Blood culture X2 and urine from PND, u/a negative. Pt with dry\n cough. Using incentive spirometer. Given Tylenol 650 mg po for c/o\n hip pain. All access sites clean, without signs of infection.\n Response:\n awaiting culture results\n Plan:\n Monitor T, Tylenol prn for T to keep HR down. Follow up on cultures.\n Enc inc .\n" }, { "category": "Echo", "chartdate": "2131-10-09 00:00:00.000", "description": "Report", "row_id": 62778, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function.\nHeight: (in) 63\nWeight (lb): 140\nBSA (m2): 1.66 m2\nBP (mm Hg): 99/56\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 11:08\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF. TDI E/e' >15, suggesting\nPCWP>18mmHg. Transmitral Doppler and TVI c/w Grade II (moderate) LV diastolic\ndysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; apex - hypo; remaining LV segments contract normally.\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: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus.\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 mild regional left ventricular systolic dysfunction with severe\nhypokinesis of the anterior wall, anterior septum and apex and mild\nhypokinesis of the anterolateral wall. Overall left ventricular systolic\nfunction is mild to moderately depressed (LVEF= 40 %). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg).\nTransmitral Doppler and tissue velocity imaging are consistent with Grade II\n(moderate) LV diastolic dysfunction. The remaining left ventricular segments\ncontract normally. Right ventricular chamber size and free wall motion are\nnormal. The number of aortic valve leaflets cannot be determined. The aortic\nvalve leaflets are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. There\nis an anterior space which most likely represents a fat pad.\n\nIMPRESSION: Mild to moderate regional left ventricular dysfunction c/w\ncoronary artery disease (LAD territory). Moderate diastolic dysfunction with\nelevated filling pressures.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular dysfunction is now present.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1045023, "text": " 12:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Placement of Baloon pump\n Admitting Diagnosis: STEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with s/p acute anterior MI with IA Baloon pump with Swanz in\n place\n REASON FOR THIS EXAMINATION:\n Placement of Baloon pump\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n INDICATION: Balloon pump assessment.\n\n Intra-aortic balloon pump has been advanced, and now terminates about 5.5 cm\n below the superior aspect of the aortic knob. Swan-Ganz catheter terminates\n in proximal left pulmonary artery. Rapidly improving pulmonary edema is\n present with residual perihilar edema as well as peripheral septal thickening.\n Small pleural effusions are also noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1045158, "text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval placement of IABP\n Admitting Diagnosis: STEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with cardiogenic shock s/p STEMI, now with IABP.\n REASON FOR THIS EXAMINATION:\n please eval placement of IABP\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:41 AM\n IABP metallic marker is 9.5 cm below the top of the aortic knob, too low.\n Interstitial edema slightly improved.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n REASON FOR EXAM: 56-year-old woman with cardiogenic shock, status post STEMI,\n now with IABP; please evaluate placement.\n\n Since yesterday, IABP is lower, with the metallic marker 9.5 cm below the top\n of the aortic knob. Swan-Ganz catheter ends in the left pulmonary artery.\n\n Interstitial edema slightly improved. There is no other change since\n yesterday.\n\n" }, { "category": "Radiology", "chartdate": "2131-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1045159, "text": ", D. 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval placement of IABP\n Admitting Diagnosis: STEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with cardiogenic shock s/p STEMI, now with IABP.\n REASON FOR THIS EXAMINATION:\n please eval placement of IABP\n ______________________________________________________________________________\n PFI REPORT\n IABP metallic marker is 9.5 cm below the top of the aortic knob, too low.\n Interstitial edema slightly improved.\n\n" }, { "category": "Radiology", "chartdate": "2131-10-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044872, "text": " 5:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA, effusion, assess line placement\n Admitting Diagnosis: STEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with STEMI, now on balloon pump, has Swan\n REASON FOR THIS EXAMINATION:\n assess for PNA, effusion, assess line placement\n ______________________________________________________________________________\n WET READ: JXRl SUN 7:51 PM\n Right perihilar opacities concerning for pneumonia or edema. Recommend\n radiographic follow-up. SG tip in expected location of main pulmonary artery.\n IABP in descending aorta, below left main bronchus. d/w Dr \n 750pm .\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n COMPARISON: None.\n\n HISTORY: 56-year-old woman with STEMI now on a balloon pump and has a\n Swan-Ganz catheter. Assess for pneumonia, effusion and assess for line\n placement.\n\n FINDINGS: The tip of the intraaortic balloon pump is somewhat difficult to\n assess but appears to be in appropriate position 3.7 cm from the aortic arch.\n The tip of the Swan-Ganz catheter is also difficult to assess but appears to\n project over the mediastinum at the level of the left mainstem bronchus.\n There is a rectangular radiodense object approximately 3.8 cm below the left\n mainstem bronchus of uncertain etiology. These findings were discussed with\n Dr. at 9:25 a.m. on and they reported that\n the balloon pump and the Swan-Ganz catheter were functioning appropriately\n however we made a recommendation to repeat radiographs to better confirm\n positioning.\n\n The cardiac silhouette is normal in size. The mediastinal contours are\n unremarkable. There are bilateral areas of consolidation predominantly in the\n right prehilar space with visible air bronchograms suggestive of pneumonia or\n pulmonary edema. A similar pattern although less prominent was also seen in\n the left prehilar space. There are bilateral Kerley B lines more prominent on\n the right again suggestive of pulmonary edema. There are no pleural\n effusions. There is no pneumothorax.\n\n IMPRESSION:\n 1. Absolute position of the intraaortic balloon pump and Swan-Ganz catheter\n is difficult to assess on this study but they appear to be in appropriate\n position however would recommend repeat radiograph to confirm position. These\n findings were discussed with Dr. and they reported that the\n intraaortic balloon pump and Swan-Ganz catheter were functioning\n appropriately.\n 2. Bilateral prehilar areas of consolidation more prominent on the right\n suggestive of pulmonary edema. However pneumonia cannot be excluded. Would\n (Over)\n\n 5:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA, effusion, assess line placement\n Admitting Diagnosis: STEMI\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n recommend repeat imaging following appropriate therapy.\n\n\n" }, { "category": "ECG", "chartdate": "2131-10-11 00:00:00.000", "description": "Report", "row_id": 117700, "text": "Sinus tachycardia. Extensive anterolateral ST-T wave elevations indicating\nongoing myocardial injury. There are also ST segment depressions in\nleads III and aVF. Compared to the previous tracing of the ST segment\ndepressions in leads III and aVF are actually slightly worse.\n\n" }, { "category": "ECG", "chartdate": "2131-10-11 00:00:00.000", "description": "Report", "row_id": 117701, "text": "Sinus rhythm. Compared to the previous tracing the heart rate is decreased.\nOtherwise, no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2131-10-10 00:00:00.000", "description": "Report", "row_id": 117702, "text": "Sinus tachycardia. Acute anterior wall myocardial infarction. Compared to the\nprevious tracing of heart rate has increased. Otherwise, no major\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2131-10-10 00:00:00.000", "description": "Report", "row_id": 117703, "text": "Sinus rhythm. Extensive anterolateral myocardial infarction. Compared to the\nprevious tracing of continuing evolving anteroseptal myocardial\ninfarction pattern is manifest.\n\n" }, { "category": "ECG", "chartdate": "2131-10-09 00:00:00.000", "description": "Report", "row_id": 117704, "text": "Sinus rhythm. Extensive anterolateral myocardial infarction, recent\nby serial tracings. Low limb lead voltage. Since the previous tracing\nof no change.\n\n" }, { "category": "ECG", "chartdate": "2131-10-08 00:00:00.000", "description": "Report", "row_id": 117705, "text": "Sinus rhythm. Compared to the previous tracing anterolateral myocardial\ninfarction pattern persists.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2131-10-07 00:00:00.000", "description": "Report", "row_id": 117746, "text": "Sinus rhythm. Compared to the previous tracing anterolateral myocardial\ninfarction pattern persists.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2131-10-07 00:00:00.000", "description": "Report", "row_id": 117747, "text": "Sinus rhythm. Anterolateral ST segment elevation myocardial infarction.\nCompared to the previous tracing of ST segment elevations are new.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2182-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680057, "text": " 64 year old restrained driver. Sent to IR for coiling of spleen\n rupture.\n Acute Pain\n Assessment:\n Pt using less fentanyl PCA this shift. Only pushing PCA 2-3 times per\n hour but increases with activity.\n Action:\n Tylenol given PRN for pain.\n Response:\n Pt currently denies any discomfort.\n Plan:\n ? Increase to PO dosage pain control once diet is advanced. Continue\n with po Tylenol prn.\n Pneumothorax, traumatic\n Assessment:\n Lung sounds diminished to bases. Pt able to move and turn side to side\n on own with some encouragement and supervision. Chest tube remains to\n H20 seal. Chest tube draining serosangious and increased since last\n night.\n Action:\n Pt encouraged to deep breath and cough. Pt encouraged to turn side to\n side.\n Response:\n Pt continues to have difficulty turning side to side but improving\n since previous night.\n Plan:\n ? off of bedrest today. Up to chair and ? transfer to floor. Encourage\n IS use. ? remove chest tube today.\n Ativan given 0.5mg for HS as pt feeling anxious. Settle\n with Ativan.\n Dermitis to elbows, knees and big toes bilaterally. Dapsone\n home dose given po. ? Hydrocortisone cream prn or pt family may bring\n from home.\n HCT continue q 6hours. Stable last completed at 11pm HCT at\n 29.\n" }, { "category": "Nursing", "chartdate": "2182-07-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 680153, "text": "Pneumothorax, traumatic\n Assessment:\n Lung sounds diminished on the right. SPO2 >93% on 4L nasal cannula.\n Action:\n Chest tube clamped by trauma surgery physicians. To receive chest xray\n at 1100.\n Out of bed to chair. IS, coughing and deep breathing, etc.\n Response:\n Pending chest xray. SPO2 and work of breathing remain normal.\n Plan:\n Possibly d/c chest tube later today.\n Wean oxygen as tolerated.\n Continue rehabilitation techniques.\n Acute Pain\n Assessment:\n Complains of right flank and chest pain on inspiration.\n Action:\n Percocet as needed.\n Fentanyl PCA discontinued\n Response:\n Pain at rest, tolerating pulmonary toileting and activity.\n \nt need 2 percocet, they\nre making me loopy\n Plan:\n Use 1 tab percocet for ongoing pain.\n Trauma, s/p\n Assessment:\n Hct stable ~29\n Hemodynamically stable\n Action:\n Hct q8\n Activity liberalized; out of bed to chair / commode\n Response:\n Tolerated activity well\n Plan:\n Next hct at 1600\n D/C Foley tonight?\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n S/O MOTOR VEHICLE ACCIDEMT\n Code status:\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 82 kg\n Allergies/Reactions:\n Gluten\n Rash;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: hypothyroidism, dermatitis\n Surgery / Procedure and date: right chest tube placement in ED\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:67\n Temperature:\n 98.4\n Arterial BP:\n S:140\n D:69\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 365 mL\n 24h total out:\n 1,232 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 05:04 AM\n Potassium:\n 3.4 mEq/L\n 05:04 AM\n Chloride:\n 105 mEq/L\n 05:04 AM\n CO2:\n 28 mEq/L\n 05:04 AM\n BUN:\n 9 mg/dL\n 05:04 AM\n Creatinine:\n 0.4 mg/dL\n 05:04 AM\n Glucose:\n 97 mg/dL\n 05:04 AM\n Hematocrit:\n 28.9 %\n 05:04 AM\n Finger Stick Glucose:\n 103\n 09:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: husband & daughter in law on admission\n / Money:\n No money / \n Cash / Credit cards sent home with: pocket book sent home with husband\n & daughter in law on night of admission\n Jewelry:\n Transferred from: CC564\n Transferred to: CC608\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nutrition", "chartdate": "2182-07-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 680165, "text": "64 year old female S/P MVA. Diet advanced to regular diet. RN\n patient had\nfirst real meal\n this morning and ate 100% of breakfast\n tray and had a little nausea afterwards. Potential for nutrition risk.\n Patient being monitored.\n Recommendations:\n 1. encourage po intake\n 2. monitor need for supplements\n 3. will follow page with questions\n" }, { "category": "Physician ", "chartdate": "2182-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 680139, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n PMH: hypothyroidism\n PSH: abdominoplasty\n : thyroid replacement\n Current medications:\n . Acetaminophen 3. Calcium Gluconate 4. Calcium Carbonate 5. Dapsone 6.\n Famotidine 7. Fentanyl PCA ; Percocet. Insulin 9. Lorazepam 10.\n Magnesium Sulfate 11. Metoclopramide 12. Potassium Chloride 13.\n Potassium Phosphate\n Thyroid\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:53 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: 37.2\nC (99\n HR: 77 (65 - 87) bpm\n BP: 161/82(115) {130/60(86) - 167/84(119)} mmHg\n RR: 19 (15 - 28) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82 kg (admission): 81 kg\n Total In:\n 2,448 mL\n 112 mL\n PO:\n 1,000 mL\n Tube feeding:\n IV Fluid:\n 1,448 mL\n 112 mL\n Blood products:\n Total out:\n 2,700 mL\n 652 mL\n Urine:\n 2,160 mL\n 592 mL\n NG:\n Stool:\n Drains:\n Balance:\n -252 mL\n -540 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.47/42/89.//6\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral , Diminished bases: ),\n Abdominal: Soft, Non-tender, Bowel sounds present, , mild distention\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 109 K/uL\n 10.0 g/dL\n 83 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.9 %\n 4.7 K/uL\n [image002.jpg]\n 01:44 PM\n 05:17 PM\n 08:38 PM\n 12:35 AM\n 04:59 AM\n 10:53 AM\n 11:01 AM\n 11:39 PM\n 05:04 AM\n 05:20 AM\n WBC\n 5.4\n 4.7\n Hct\n 28.7\n 28.8\n 29.3\n 27.1\n 27.3\n 27.4\n 26.9\n 29.0\n 28.9\n Plt\n 85\n 90\n 84\n 109\n Creatinine\n 0.4\n TCO2\n 31\n Glucose\n 83\n Other labs: PT / PTT / INR:13.8/25.6/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:454 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.6\n mg/dL, Mg:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan:\n 64 yo f s/p mvc with mult R sided rib fxs, R chest tube and splenic lac\n s.p angio coiling but cont'd slow hct drop\n Neurologic: : Neuro checks Q:4 Pain: Aceaminophen 1000 mg po q 6 h, d/c\n fentanyl PCA-pain controlled percocets\n Cardiovascular: CV stable s/p cardio, s/p CEs neg x 3\n Pulmonary: Rt ptx s/p CT placement,O2 sats good on NC, CT to water\n seal: small PTX CXR :\n Gastrointestinal / Abdomen: extensive splenic lacs embolized by IR,+\n BM; ADAT to regular diet\n Renal: Foley, Cr 0.6 on admit, follow UOP\n Hematology: Stable anemia.\n Endocrine: RISS, cont thryroid supplement\n Infectious Disease: no issues, afebrile\n Lines / Tubes / Drains: PIV x3, foley, Rt CT, L radial art line\n Fluids: KVO\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: Arterial Line - 04:45 AM; 18 Gauge - 10:57\n AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full\n Disposition: Transfer to floor\n Total time spent: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2182-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 680140, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n PMH: hypothyroidism\n PSH: abdominoplasty\n : thyroid replacement\n Current medications:\n . Acetaminophen 3. Calcium Gluconate 4. Calcium Carbonate 5. Dapsone 6.\n Famotidine 7. Fentanyl PCA ; Percocet. Insulin 9. Lorazepam 10.\n Magnesium Sulfate 11. Metoclopramide 12. Potassium Chloride 13.\n Potassium Phosphate\n Thyroid\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:53 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: 37.2\nC (99\n HR: 77 (65 - 87) bpm\n BP: 161/82(115) {130/60(86) - 167/84(119)} mmHg\n RR: 19 (15 - 28) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82 kg (admission): 81 kg\n Total In:\n 2,448 mL\n 112 mL\n PO:\n 1,000 mL\n Tube feeding:\n IV Fluid:\n 1,448 mL\n 112 mL\n Blood products:\n Total out:\n 2,700 mL\n 652 mL\n Urine:\n 2,160 mL\n 592 mL\n NG:\n Stool:\n Drains:\n Balance:\n -252 mL\n -540 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.47/42/89.//6\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral , Diminished bases: ),\n Abdominal: Soft, Non-tender, Bowel sounds present, , mild distention\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 109 K/uL\n 10.0 g/dL\n 83 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.9 %\n 4.7 K/uL\n [image002.jpg]\n 01:44 PM\n 05:17 PM\n 08:38 PM\n 12:35 AM\n 04:59 AM\n 10:53 AM\n 11:01 AM\n 11:39 PM\n 05:04 AM\n 05:20 AM\n WBC\n 5.4\n 4.7\n Hct\n 28.7\n 28.8\n 29.3\n 27.1\n 27.3\n 27.4\n 26.9\n 29.0\n 28.9\n Plt\n 85\n 90\n 84\n 109\n Creatinine\n 0.4\n TCO2\n 31\n Glucose\n 83\n Other labs: PT / PTT / INR:13.8/25.6/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:454 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.6\n mg/dL, Mg:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan:\n 64 yo f s/p mvc with mult R sided rib fxs, R chest tube and splenic lac\n s.p angio coiling but cont'd slow hct drop\n Neurologic: : Neuro checks Q:4 Pain: Aceaminophen 1000 mg po q 6 h, d/c\n fentanyl PCA-pain controlled percocets\n Cardiovascular: CV stable s/p cardio, s/p CEs neg x 3\n Pulmonary: Rt ptx s/p CT placement,O2 sats good on NC, CT to water\n seal: small PTX CXR :\n Gastrointestinal / Abdomen: extensive splenic lacs embolized by IR,+\n BM; ADAT to regular diet\n Renal: Foley, Cr 0.6 on admit, follow UOP\n Hematology: Stable anemia.\n Endocrine: RISS, cont thryroid supplement\n Infectious Disease: no issues, afebrile\n Lines / Tubes / Drains: PIV x3, foley, Rt CT, L radial art line\n Fluids: KVO\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: Arterial Line - 04:45 AM; 18 Gauge - 10:57\n AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full\n Disposition: Transfer to floor\n Total time spent: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2182-06-28 00:00:00.000", "description": "Intensivist Note", "row_id": 679516, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n Chief complaint:\n Splenic las s/p embolization with Hct slowly trending down\n PMHx:\n PMH: hypothyroidism\n PSH: abdominoplasty\n : thyroid replacement\n Current medications:\n 1000 mL LR 3. 1000 mL LR 4. Acetaminophen 5. Calcium Gluconate 6.\n Famotidine 7. Fentanyl PCA\n 8. Insulin 9. Magnesium Sulfate 10. Metoclopramide 11. Ondansetron 12.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ANGIOGRAPHY - At 08:00 AM\n splenic angiogram\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 02:00 PM\n Famotidine (Pepcid) - 08:23 PM\n Other medications:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.1\nC (98.8\n HR: 76 (49 - 87) bpm\n BP: 126/63(87) {80/44(57) - 143/72(96)} mmHg\n RR: 15 (14 - 35) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,884 mL\n 512 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,834 mL\n 512 mL\n Blood products:\n 1,050 mL\n Total out:\n 2,004 mL\n 205 mL\n Urine:\n 884 mL\n 165 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,880 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 129 K/uL\n 9.1 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 110 mEq/L\n 141 mEq/L\n 25.1 %\n 8.3 K/uL\n [image002.jpg]\n 04:16 AM\n 04:25 AM\n 12:31 PM\n 04:26 PM\n 08:09 PM\n 12:31 AM\n 04:05 AM\n WBC\n 11.2\n 11.2\n 8.3\n Hct\n 32.2\n 34\n 28.8\n 30.8\n 27.6\n 26.3\n 25.1\n Plt\n 137\n 168\n 129\n Creatinine\n 0.6\n 0.6\n 0.7\n 0.6\n Troponin T\n <0.01\n <0.01\n <0.01\n Glucose\n 167\n 159\n 145\n 117\n Other labs: PT / PTT / INR:14.0/22.2/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:172 mg/dL, Lactic Acid:2.7 mmol/L, Ca:6.8\n mg/dL, Mg:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .Neurologic: Neuro checks Q:4, C-collar until C-spine clear. f/u all CT\n scans (head, C-spine, Chest, abd, pelvis). Pain: Aceaminophen 1000 mg\n po q 6 h, fentanyl 25-100 mcg q 2 hr prn pain\n Cardiovascular: Stable\n Pulmonary: Rt ptx s/p CT placement,. Will continue chest tube for small\n air leak. Resp- spon, O2 (placed on NRB by ED, wean as tol)\n Gastrointestinal / Abdomen: extensive splenic lacs, follow serial Hct,\n NPO; Splenic artery embolized\n Renal: Foley, Adequate UO, Required a couple of fluid boluses .\n Hematology: HEME: q 4 hr Hct drifting down to 25\n Endocrine: RISS, check TSH, restart thyroid replacement\n Infectious Disease: No issues\n Lines / Tubes / Drains: PIV x3, foley, Rt CT, L radial art line\n Fluids: LR @ 100 ml/hr\n Consults: Trauma surgery\n Billing Diagnosis:\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: 16 Gauge - 04:40 AM\n Arterial Line - 04:45 AM\n 18 Gauge - 10:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679848, "text": "Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2182-06-29 00:00:00.000", "description": "Intensivist Note", "row_id": 679747, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n Chief complaint:\n s/p mvc\n PMHx:\n hypothyroidism\n s/p abdominoplasty\n Current medications:\n 1. IV access: Peripheral line, Date inserted: Order date:\n @ 0338 9. Magnesium Sulfate IV Sliding Scale Order date: @\n 1317\n 2. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 1748 10. Metoclopramide 10\n mg IV Q6H:PRN nausea Order date: @ 1358\n 3. Acetaminophen 1000 mg PO Q6H:PRN pain, fever Order date: @\n 0338 11. Neutra-Phos 1 PKT PO ONCE Duration: 1 Doses Order date: \n @ 2224\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1317 12.\n Neutra-Phos 1 PKT PO ONCE Duration: 1 Doses Order date: @ 2231\n 5. Calcium Carbonate 1000 mg PO QID:PRN low calcium Order date: \n @ 2231 13. Neutra-Phos 2 PKT PO ONCE Duration: 1 Doses Order date:\n @ 0306\n 6. Famotidine 20 mg PO BID Order date: @ 0839 14. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1648\n 7. Fentanyl PCA 12.5 mcg IVPCA Lockout Interval: 6 minutes Basal Rate:\n 0 mcg(s)/hour 1-hr Max Limit: 100 mcg(s) Order date: @ 1456 15.\n 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: @ 0338\n 8. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: \n @ 0534 16. Thyroid 90 mg PO DAILY Order date: @ 0844\n 24 Hour Events:\n increased maintenance fluids to eval for post-constrast nephropathy.\n Serial hcts followed and dropped from 25-->21 and was transfused 2U\n PRBCS\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:34 PM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.8\nC (98.3\n HR: 78 (73 - 89) bpm\n BP: 140/65(94) {125/60(85) - 157/79(103)} mmHg\n RR: 17 (14 - 33) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,562 mL\n 756 mL\n PO:\n 300 mL\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,262 mL\n 440 mL\n Blood products:\n 216 mL\n Total out:\n 1,215 mL\n 570 mL\n Urine:\n 905 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,347 mL\n 186 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: ///27/\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-tender, Bowel sounds present, Distended, mild\n distention, no r/g/r\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 89 K/uL\n 6.9 g/dL\n 91 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 142 mEq/L\n 20.7 %\n 5.0 K/uL\n [image002.jpg]\n 04:26 PM\n 08:09 PM\n 12:31 AM\n 04:05 AM\n 07:38 AM\n 12:06 PM\n 03:46 PM\n 05:54 PM\n 08:11 PM\n 01:44 AM\n WBC\n 11.2\n 8.3\n 5.0\n Hct\n 30.8\n 27.6\n 26.3\n 25.1\n 25.2\n 24.5\n 22.7\n 22.6\n 22.8\n 20.7\n Plt\n 168\n 129\n 89\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.4\n 0.4\n Troponin T\n <0.01\n Glucose\n 145\n 117\n 96\n 91\n Other labs: PT / PTT / INR:14.0/22.2/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:172 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.1\n mg/dL, Mg:2.0 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan: 64 yo f s/p mvc with mult R sided rib fxs, R chest\n tube and splenic lac s.p angio coiling but cont'd slow hct drop\n Neurologic: Neuro checks Q: hr, Pain controlled, Neuro checks Q:4\n Aceaminophen 1000 mg po q 6 h, fentanyl 25-100 mcg q 2 hr prn pain.\n Cardiovascular: Stable\n Pulmonary: Rt ptx s/p CT placement,O2 sats good on NC\n Gastrointestinal / Abdomen: extensive splenic lacs embolized by IR,\n consider return to IR if cont'd hct drop\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct.Transfuse\n Endocrine: RISS, cont thyroid supplement\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Fluids: LR at 75\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:40 AM\n Arterial Line - 04:45 AM\n 18 Gauge - 10:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Code status:\n Disposition: TSICU\n Total time spent: 32\n" }, { "category": "Nursing", "chartdate": "2182-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679909, "text": "Pneumothorax, traumatic\n Assessment:\n Pt s/p motor vehicle accident. Pt has right sided rib fractures.\n Action:\n Pt encouraged side to side turning. Chest tube remains to H2O seal.\n Response:\n Chest tube draining serosanginous drainage.\n Plan:\n Encourage IS use. Pulmonary toileting. Bedrest until Monday as per\n order. Monitor HCT q 4 hours. ? removal of chest tube today.\n Acute Pain\n Assessment:\n Pt c/o pain to right chest. Fentanyl PCA under used as pt needs\n reminders to push button when pain is present.\n Action:\n Tylenol given po q 6-8 hours prn for pain.\n Response:\n Pain down to on pain scale.\n Plan:\n Continue to encourage PCA. ? use of oxycodone for longer lasting\n effect or change Tylenol around the clock.\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679854, "text": "Trauma, s/p\n Assessment:\n MVC with extensive splenic LACS, multiple R rib fx, s/p angio coiling\n to splenic LACS, continues with slow hct drop, 0200 hct 20, tx with 2 u\n pc\ns last noc, post tx hct 29.3, R pleural ct draining mod amt serosang\n material, no air leak or crepitus noted\n Action:\n HCT q 4 hrs, coags x 2 today, plt ct x 1, ct placed to water seal\n Response:\n Repeat hcts stable @ 28.7-28.8, plt/inr stable\n Plan:\n Continue to monitor for splenic bleeding, keep npo except meds, ivf @\n 75/hr while npo, frequent labs as ordered\n Acute Pain\n Assessment:\n Pt on fentanyl PCA, at rest c/o mild pain to R chest from rib fx\n pain worsening with turning, # 10 pain @ times with turning\n Action:\n Encouraged to use PCA, encouraged to turn on own @ own pace to ease\n pain, assist given as needed\n Response:\n Pt states fentanyl PCA dose adequate for her, did not want extra dose\n with turning, pain does subside after turning\n Plan:\n Continue to assess pain control, prn po Tylenol as ordered\n" }, { "category": "Nursing", "chartdate": "2182-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680010, "text": "TITLE:\n Pneumothorax, traumatic\n Assessment:\n CT on H20 seal.+ air leak when coughing, + fluctuation. Draining approx\n 60cc serosang. fluid every few hrs. Lungs clear and diminished at\n bases-LLL less diminished today. Remains on 4L NC. Weak non-productive\n cough.\n Action:\n CT maintained. CXR obtained this am. IS and C/DB encouraged.\n Response:\n O2 sats decrease to high 80\ns on room air, though are >93% on 4L NC.\n Reaches 750 on IS.\n Plan:\n Trauma to most likely d/c CT tomorrow. Continue pulmonary hygiene.\n Acute Pain\n Assessment:\n c/o aching pain in R ribs, describes pain as when moving but\n doesn\nt have any pain at rest.\n Action:\n Pt repositioned Q2, and Tylenol provided Q6. Fentanyl PCA at 12.5mcg\n continues. Cough pillow use encouraged.\n Response:\n Able to turn with min assistance and reports pain is adequately\n controlled.\n Plan:\n Consider changing PCA to oxycodone now that pt is on clear liquids\n diet.\n Q6 hct followed-am hct 1100-pm hct pending.\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679717, "text": "Pneumothorax, traumatic\n Assessment:\n Right CT to 20cm wall suction\n draining moderate amounts sero-sang\n drainage. + fluctuation. No crepitus. LSCTA\n diminished at bases.\n Weak, non-productive cough. O2 sats >93% on 4L NC.\n Action:\n Maintained CT. Encouraged c&db and IS use.\n Response:\n CT intact\n dressing cdi. Using IS with good technique.\n Plan:\n Pulmonary hygiene. CT to water seal? Wean O2.\n Trauma, s/p\n Assessment:\n Hct 21 (22). Hemodynamicaly stable. Adequate u/o. Abdomen soft/nt/nd.\n Action:\n Transfusing 2 units prbc as ordered.\n Response:\n Pt tolerating blood well.\n Plan:\n Check post-transfusion hct. Bed rest until Monday.\n Acute Pain\n Assessment:\n Pt c/o right flank/chest wall pain\n worsening with movement and\n coughing.\n Action:\n Encouraged PCA use and administered Tylenol q6 hours.\n Response:\n Reporting adequate pain control and observed resting comfortably\n throughout the night.\n Plan:\n Continue to monitor pain level and encourage pca use.\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679719, "text": "Pneumothorax, traumatic\n Assessment:\n Right CT to 20cm wall suction\n draining moderate amounts sero-sang\n drainage. + fluctuation. No crepitus. LSCTA\n diminished at bases.\n Weak, non-productive cough. O2 sats >93% on 4L NC.\n Action:\n Maintained CT. Encouraged c&db and IS use.\n Response:\n CT intact\n dressing cdi. Using IS with good technique.\n Plan:\n Pulmonary hygiene. CT to water seal? Wean O2.\n Trauma, s/p\n Assessment:\n Hct 21 (22). Hemodynamicaly stable. Adequate u/o. Abdomen soft/nt/nd.\n Action:\n Transfusing 2 units prbc as ordered.\n Response:\n Pt tolerating blood well.\n Plan:\n Check post-transfusion hct. Bed rest until Monday.\n Acute Pain\n Assessment:\n Pt c/o right-sided pain (from rib fx)\n worsening with movement and\n coughing.\n Action:\n Encouraged PCA use and administered Tylenol q6 hours.\n Response:\n Reporting adequate pain control and was observed resting comfortably\n throughout the night.\n Plan:\n Continue to monitor pain level and encourage pca use. Consider\n transition to ivp/po narcotics.\n" }, { "category": "Physician ", "chartdate": "2182-06-29 00:00:00.000", "description": "Intensivist Note", "row_id": 679721, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n Chief complaint:\n s/p mvc\n PMHx:\n hypothyroidism\n s/p abdominoplasty\n Current medications:\n 1. IV access: Peripheral line, Date inserted: Order date:\n @ 0338 9. Magnesium Sulfate IV Sliding Scale Order date: @\n 1317\n 2. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 1748 10. Metoclopramide 10\n mg IV Q6H:PRN nausea Order date: @ 1358\n 3. Acetaminophen 1000 mg PO Q6H:PRN pain, fever Order date: @\n 0338 11. Neutra-Phos 1 PKT PO ONCE Duration: 1 Doses Order date: \n @ 2224\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1317 12.\n Neutra-Phos 1 PKT PO ONCE Duration: 1 Doses Order date: @ 2231\n 5. Calcium Carbonate 1000 mg PO QID:PRN low calcium Order date: \n @ 2231 13. Neutra-Phos 2 PKT PO ONCE Duration: 1 Doses Order date:\n @ 0306\n 6. Famotidine 20 mg PO BID Order date: @ 0839 14. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1648\n 7. Fentanyl PCA 12.5 mcg IVPCA Lockout Interval: 6 minutes Basal Rate:\n 0 mcg(s)/hour 1-hr Max Limit: 100 mcg(s) Order date: @ 1456 15.\n 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: @ 0338\n 8. Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: \n @ 0534 16. Thyroid 90 mg PO DAILY Order date: @ 0844\n 24 Hour Events:\n increased maintenance fluids to eval for post-constrast nephropathy.\n Serial hcts followed and dropped from 25-->21 and was transfused 2U\n PRBCS\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:34 PM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.8\nC (98.3\n HR: 78 (73 - 89) bpm\n BP: 140/65(94) {125/60(85) - 157/79(103)} mmHg\n RR: 17 (14 - 33) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,562 mL\n 756 mL\n PO:\n 300 mL\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,262 mL\n 440 mL\n Blood products:\n 216 mL\n Total out:\n 1,215 mL\n 570 mL\n Urine:\n 905 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,347 mL\n 186 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: ///27/\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-tender, Bowel sounds present, Distended, mild\n distention, no r/g/r\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 89 K/uL\n 6.9 g/dL\n 91 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 142 mEq/L\n 20.7 %\n 5.0 K/uL\n [image002.jpg]\n 04:26 PM\n 08:09 PM\n 12:31 AM\n 04:05 AM\n 07:38 AM\n 12:06 PM\n 03:46 PM\n 05:54 PM\n 08:11 PM\n 01:44 AM\n WBC\n 11.2\n 8.3\n 5.0\n Hct\n 30.8\n 27.6\n 26.3\n 25.1\n 25.2\n 24.5\n 22.7\n 22.6\n 22.8\n 20.7\n Plt\n 168\n 129\n 89\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.4\n 0.4\n Troponin T\n <0.01\n Glucose\n 145\n 117\n 96\n 91\n Other labs: PT / PTT / INR:14.0/22.2/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:172 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.1\n mg/dL, Mg:2.0 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan: 64 yo f s/p mvc with mult R sided rib fxs, R chest\n tube and splenic lac s.p angio coiling but cont'd slow hct drop\n Neurologic: Neuro checks Q: hr, Pain controlled, Neuro checks Q:4\n Aceaminophen 1000 mg po q 6 h, fentanyl 25-100 mcg q 2 hr prn pain.\n Cardiovascular: Rt ptx s/p CT placement,O2 sats good on NC\n Pulmonary: Rt ptx s/p CT placement,O2 sats good on NC\n Gastrointestinal / Abdomen: extensive splenic lacs embolized by IR,\n consider return to IR if cont'd hct drop\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS, cont thyroid supplement\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:40 AM\n Arterial Line - 04:45 AM\n 18 Gauge - 10:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2182-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679986, "text": "TITLE:\n Pneumothorax, traumatic\n Assessment:\n CT on H20 seal.+ air leak when coughing, + fluctuation. Draining approx\n 60cc serosang. fluid every few hrs. Lungs clear and diminished at\n bases-LLL less diminished today. Remains on 4L NC. Weak non-productive\n cough.\n Action:\n CT maintained. CXR obtained this am. IS and C/DB encouraged.\n Response:\n O2 sats decrease to high 80\ns on room air, though are >93% on 4L NC.\n Reaches 750 on IS.\n Plan:\n Trauma to most likely d/c CT tomorrow. Continue pulmonary hygiene.\n Acute Pain\n Assessment:\n c/o aching pain in R ribs, describes pain as when moving but\n doesn\nt have any pain at rest.\n Action:\n Pt repositioned Q2, and Tylenol provided Q6. Fentanyl PCA at 12.5mcg\n continues. Cough pillow use encouraged.\n Response:\n Able to turn with min assistance and reports pain is adequately\n controlled.\n Plan:\n Consider changing PCA to oxycodone now that pt is on clear liquids\n diet.\n *Hct stable at 27.\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679709, "text": "Pneumothorax, traumatic\n Assessment:\n CT to suction\n draining moderate amounts sero-sanguinous drainage\n Action:\n Response:\n Plan:\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679713, "text": "Pneumothorax, traumatic\n Assessment:\n Right CT to 20cm wall suction\n draining moderate amounts sero-sang\n drainage. + fluctuation. No crepitus. LSCTA\n diminished at bases. O2\n sats >93% on 4L NC.\n Action:\n Encouraged c&db and IS use.\n Response:\n Plan:\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679715, "text": "Pneumothorax, traumatic\n Assessment:\n Right CT to 20cm wall suction\n draining moderate amounts sero-sang\n drainage. + fluctuation. No crepitus. LSCTA\n diminished at bases.\n Weak, non-productive cough. O2 sats >93% on 4L NC.\n Action:\n Maintained CT. Encouraged c&db and IS use.\n Response:\n CT intact\n dressing cdi. Using IS with good technique.\n Plan:\n Pulmonary hygiene. CT to water seal? Wean O2.\n Trauma, s/p\n Assessment:\n Hct 21 (22). Hemodynamicaly stable.\n Action:\n Transfusing 2 units prbc as ordered.\n Response:\n Pt tolerating blood well.\n Plan:\n Check post-transfusion hct.\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679710, "text": "Pneumothorax, traumatic\n Assessment:\n CT to 20cm wall suction\n draining moderate amounts sero-sanguinous\n drainage\n Action:\n Response:\n Plan:\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-06-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 679633, "text": "64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n Pneumothorax, traumatic\n Assessment:\n R CT to 20cm wall sxn. Sm crepidus at site, + fluctuation, occasional\n leak observed. Draining sm amts serosang. drainge. Weak non productive\n cough. Lungs clear and equal diminished bibasilar. O2 sats >93% on 3L\n NC.\n Action:\n CT dsg changed this am. C/DB encouraged, IS teaching done.\n Response:\n CT maintained, insertion site WNl. Reaches 750 on IS.\n Plan:\n Follow CXRs, ? H20 seal tomorrow. Continue aggressive pulm .hygiene,\n wean supplemental O2.\n Acute Pain\n Assessment:\n Reports R sided rib fxs as primary source of pain. Describes pain as\n dull/achey and 2 at best and 6 at worst with movement.\n Action:\n Fentanyl PCA 12.5mcg and 1gm Tylenol Q6.\n Response:\n Pt reports pain is well controlled.\n Plan:\n Continue to assess for pain, treat with Tylenol and consider weaning to\n PO analgesia or Morphine PCA.\n Trauma, s/p\n Assessment:\n Hct 25 this am. Gradually drifting throughout day, last one at 1600\n was 22. Abd soft, non distended. u/o marginal but adequate.\n Action:\n Q4 hcts monitored\n Response:\n Hct trending down, though clinical presentation suggests pt is stable\n at this time.\n Plan:\n Continue serial hcts-next due at 1800. Monitor for other signs of\n bleeding, plan to transfuse if Hct <20, Trauma will take pt to IR if\n becomes unstable. Bedrest til Mon.\n .\n" }, { "category": "Nursing", "chartdate": "2182-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679634, "text": "64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n Pneumothorax, traumatic\n Assessment:\n R CT to 20cm wall sxn. Sm crepidus at site, + fluctuation, occasional\n leak observed. Draining sm amts serosang. drainge. Weak non productive\n cough. Lungs clear and equal diminished bibasilar. O2 sats >93% on 3L\n NC.\n Action:\n CT dsg changed this am. C/DB encouraged, IS teaching done.\n Response:\n CT maintained, insertion site WNl. Reaches 750 on IS.\n Plan:\n Follow CXRs, ? H20 seal tomorrow. Continue aggressive pulm .hygiene,\n wean supplemental O2.\n Acute Pain\n Assessment:\n Reports R sided rib fxs as primary source of pain. Describes pain as\n dull/achey and 2 at best and 6 at worst with movement.\n Action:\n Fentanyl PCA 12.5mcg and 1gm Tylenol Q6.\n Response:\n Pt reports pain is well controlled.\n Plan:\n Continue to assess for pain, treat with Tylenol and consider weaning to\n PO analgesia or Morphine PCA.\n Trauma, s/p\n Assessment:\n Hct 25 this am. Gradually drifting throughout day, last one at 1600\n was 22. Abd soft, non distended. u/o marginal but adequate.\n Action:\n Q4 hcts monitored\n Response:\n Hct trending down, though clinical presentation suggests pt is stable\n at this time.\n Plan:\n Continue serial hcts-next due at 1800. Monitor for other signs of\n bleeding, plan to transfuse if Hct <20, Trauma will take pt to IR if\n becomes unstable. Bedrest til Mon.\n .\n" }, { "category": "Nursing", "chartdate": "2182-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679871, "text": "Pneumothorax, traumatic\n Assessment:\n Pt s/p motor vehicle accident. Pt has right sided rib fractures.\n Action:\n Pt encouraged side to side turning. Chest tube remains to H2O seal.\n Response:\n Chest tube draining serosanginous drainage.\n Plan:\n Encourage IS use. Pulmonary toileting. Bedrest until Monday as per\n order. Monitor HCT q 4 hours.\n Acute Pain\n Assessment:\n Pt c/o pain to right chest. Fentanyl PCA under used as pt needs\n reminders to push button when pain is present.\n Action:\n Tylenol given po q 6-8 hours prn for pain.\n Response:\n Pain down to on pain scale.\n Plan:\n Continue to encourage PCA. ? use of oxycodone for longer lasting\n effect or change Tylenol around the clock.\n" }, { "category": "Physician ", "chartdate": "2182-06-30 00:00:00.000", "description": "Intensivist Note", "row_id": 679874, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid.\n Chief complaint:\n PMHx:\n hypothyroidism\n Current medications:\n 24 Hour Events:\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:30 PM\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: 37.4\nC (99.4\n T current: 37.2\nC (98.9\n HR: 71 (68 - 90) bpm\n BP: 144/68(96) {122/59(82) - 172/86(119)} mmHg\n RR: 26 (14 - 33) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,453 mL\n 553 mL\n PO:\n 340 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 1,413 mL\n 313 mL\n Blood products:\n 700 mL\n Total out:\n 2,165 mL\n 390 mL\n Urine:\n 1,635 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n 288 mL\n 163 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\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 : )\n Abdominal: Soft, Non-tender\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 84 K/uL\n 9.4 g/dL\n 83 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 139 mEq/L\n 27.1 %\n 5.4 K/uL\n [image002.jpg]\n 12:06 PM\n 03:46 PM\n 05:54 PM\n 08:11 PM\n 01:44 AM\n 08:50 AM\n 01:44 PM\n 05:17 PM\n 08:38 PM\n 12:35 AM\n WBC\n 5.0\n 5.4\n Hct\n 24.5\n 22.7\n 22.6\n 22.8\n 20.7\n 29.3\n 28.7\n 28.8\n 29.3\n 27.1\n Plt\n 89\n 85\n 90\n 84\n Creatinine\n 0.4\n 0.4\n 0.4\n Glucose\n 96\n 91\n 83\n Other labs: PT / PTT / INR:13.8/25.6/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:454 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.6\n mg/dL, Mg:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan: 64F s/p MVC frontseat passenger, with extensive\n splenic lacs, s/p angio & coiling\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, pain controlled on\n fentanyl PCA & acetaminophen\n Cardiovascular: stable, no current issues\n Pulmonary: NC O2 wean as tol; CT on water seal, likely DC today\n Gastrointestinal / Abdomen: likely could start diet today & adv as tol\n Nutrition: NPO, start clears\n Renal: Foley, replete lytes prn\n Hematology: Serial Hct, Hct 27.1 this am, cont to follow; plts 84,\n follow CBC\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, art line, Chest tube, PIV x3\n Wounds:\n Imaging:\n Fluids: LR, hep lock when tol po\n Consults: Trauma surgery, Interventional radiology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:40 AM\n Arterial Line - 04:45 AM\n 18 Gauge - 10:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2182-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680043, "text": "64 year old restrained driver.\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n Pneumothorax, traumatic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680044, "text": "64 year old restrained driver.\n Acute Pain\n Assessment:\n Pt using less fentanyl PCA this shift. Only pushing PCA 2-3 times per\n hour but increases with activity.\n Action:\n Tylenol given PRN for pain.\n Response:\n Plan:\n Pneumothorax, traumatic\n Assessment:\n Lung sounds diminished to bases. Pt able to move and turn side to side\n on own with some encouragement and supervision. Chest tube remains to\n H20 seal. Chest tube draining serosangious drainage.\n Action:\n Pt encouraged to deep breath and cough. Pt encouraged to turn side to\n side.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-06-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 679631, "text": "64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n Pneumothorax, traumatic\n Assessment:\n R CT to 20cm wall sxn. Sm crepidus at site, + fluctuation, occasional\n leak observed. Draining sm amts serosang. drainge. Weak non productive\n cough. Lungs clear and equal diminished bibasilar. O2 sats >93% on 3L\n NC.\n Action:\n CT dsg changed this am. C/DB encouraged, IS teaching done.\n Response:\n CT maintained, insertion site WNl. Reaches 750 on IS.\n Plan:\n Follow CXRs, ? H20 seal tomorrow. Continue aggressive pulm .hygiene,\n wean supplemental O2.\n Acute Pain\n Assessment:\n Reports R sided rib fxs as primary source of pain. Describes pain as\n dull/achey and 2 at best and 6 at worst with movement.\n Action:\n Fentanyl PCA 12.5mcg and 1gm Tylenol Q6.\n Response:\n Pt reports pain is well controlled.\n Plan:\n Continue to assess for pain, treat with Tylenol and consider weaning to\n PO analgesia or Morphine PCA.\n Trauma, s/p\n Assessment:\n Hct 25 this am. Gradually drifting throughout day, last one at 1600\n was 22. Abd soft, non distended.\n Action:\n Q4 hcts monitored\n Response:\n Hct trending down, though clinical presentation suggests pt is stable\n at this time.\n Plan:\n Continue serial hcts-next due at 1800. Monitor for other signs of\n bleeding, plan to transfuse if Hct <20, Trauma will take pt to IR if\n becomes unstable. Bedrest til Mon.\n .\n" }, { "category": "Physician ", "chartdate": "2182-06-27 00:00:00.000", "description": "Intensivist Note", "row_id": 679284, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid.\n Chief complaint:\n PMHx:\n hypothyroidism\n Current medications:\n Home meds: throid replacement\n 24 Hour Events:\n ARTERIAL LINE - START 04:45 AM\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 04:28 AM\n Other medications:\n Flowsheet Data as of 06:15 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: 37.6\nC (99.7\n HR: 59 (41 - 75) bpm\n BP: 125/62(83) {125/62(83) - 136/68(92)} mmHg\n RR: 18 (16 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Bladder pressure: 18 (18 - 18) mmHg\n Total In:\n 2,275 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,225 mL\n Blood products:\n 1,050 mL\n Total out:\n 0 mL\n 1,350 mL\n Urine:\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 925 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, A&O x3\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 : )\n Abdominal: Soft, tender over epigastrium\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 Skin: No(t) Rash:\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 137 K/uL\n 11.2 g/dL\n 159 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 111 mEq/L\n 141 mEq/L\n 34\n 11.2 K/uL\n [image002.jpg]\n 04:16 AM\n 04:25 AM\n WBC\n 11.2\n Hct\n 32.2\n 34\n Plt\n 137\n Creatinine\n 0.6\n Glucose\n 167\n 159\n Other labs: PT / PTT / INR:14.6/22.8/1.3, Fibrinogen:172 mg/dL, Lactic\n Acid:2.7 mmol/L, Ca:6.9 mg/dL, Mg:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan: 64F s/p MVC frontseat passenger, with extensive\n splenic lacs, and rt anterior rib fx 2,3,4,5; Right ptx, RML lung\n contusion, left inf pelvic ramus ? stepoff; BP initially 120's in Ed,\n then drifted down to 70's; in ED rec'd 3 U PRBCs & 3 L crystalloid.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, f/u CT head,\n CT-C-spine; cont C-collar for now; Fentanyl 25-100 mcg IV q 2 hr prn,\n Acetaminophen 1000 mg po q 6 hr prn pain.\n Cardiovascular: Monitor BP/HR, if further hypotension would d/w surgery\n Re: exp lap if indicated, tele\n Pulmonary: Spontaneous resp; placed on NRB in ED: wean O2 as tol\n Gastrointestinal / Abdomen: NPO for now, H2B\n Nutrition: NPO\n Renal: Foley, follow UOP\n Hematology: Serial Hct, Hct q 4 h\n Endocrine: RISS, check TSH, resume thyroid replacement\n Infectious Disease:\n Lines / Tubes / Drains: Foley, Chest tube - pleural\n Wounds:\n Imaging: f/u CT scan reports for CT head, chest, abd, pelvis\n Fluids:\n Consults: Trauma surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:39 AM\n 16 Gauge - 04:40 AM\n Arterial Line - 04:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2182-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679272, "text": "64F restrained passenger t-boned on passenger side with 20 minute\n extrication. In a-fib on the scene. Injuries include splenic rupture vs\n severe laceration with free fluid in the abdomen, right pneumothorax,\n right rib fractures #2,3,4,5. PMHx includes hypothyroidism and\n dermatitis. Allergic to glutens (rash).\n Trauma, s/p\n Assessment:\n No obvious external signs of trauma. Strict bedrest with minimal\n turning as per Dr. . Episode of bradycardia (sinus, 39) associated\n with hypotension (73/40).\n Action:\n Strict bed rest.\n Received 1L LR during hypotensive event\n Arterial line placed by physician\n :\n BP now stable, Hct 32, Other labs pending.\n Plan:\n Strict bed rest. Q4 hematocrit. Hemodynamic monitoring.\n Pneumothorax, traumatic\n Assessment:\n Right chest tube to 20cm H2O suction. +fluctuation\nleak\ncrepitus.\n Sanguenous output. Lung sounds clear but diminished. Complains of \n sharp pain on inspiration. Initially requiring non-rebreather.\n Action:\n Fentanyl IVP for pain management\n Weaned to 70% humidified closed face masks\n Response:\n SPO2 94-95% on current oxygen.\n Plan:\n Promote adequate analgesia to encourage adequate ventilation and\n pulmonary toileting. Maintain chest tube per routine.\n" }, { "category": "Physician ", "chartdate": "2182-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 680089, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n PMH: hypothyroidism\n PSH: abdominoplasty\n : thyroid replacement\n Chief complaint:\n PMHx:\n Current medications:\n . Acetaminophen 3. Calcium Gluconate 4. Calcium Carbonate 5. Dapsone 6.\n Famotidine 7. Fentanyl PCA\n 8. Insulin 9. Lorazepam 10. Magnesium Sulfate 11. Metoclopramide 12.\n Potassium Chloride 13. Potassium Phosphate\n 14. Sodium Chloride 0.9% Flush 15. Thyroid\n 24 Hour Events:\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:53 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: 37.2\nC (99\n HR: 77 (65 - 87) bpm\n BP: 161/82(115) {130/60(86) - 167/84(119)} mmHg\n RR: 19 (15 - 28) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82 kg (admission): 81 kg\n Total In:\n 2,448 mL\n 112 mL\n PO:\n 1,000 mL\n Tube feeding:\n IV Fluid:\n 1,448 mL\n 112 mL\n Blood products:\n Total out:\n 2,700 mL\n 652 mL\n Urine:\n 2,160 mL\n 592 mL\n NG:\n Stool:\n Drains:\n Balance:\n -252 mL\n -540 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.47/42/89.//6\n Physical Examination\n Labs / Radiology\n 109 K/uL\n 10.0 g/dL\n 83 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.9 %\n 4.7 K/uL\n [image002.jpg]\n 01:44 PM\n 05:17 PM\n 08:38 PM\n 12:35 AM\n 04:59 AM\n 10:53 AM\n 11:01 AM\n 11:39 PM\n 05:04 AM\n 05:20 AM\n WBC\n 5.4\n 4.7\n Hct\n 28.7\n 28.8\n 29.3\n 27.1\n 27.3\n 27.4\n 26.9\n 29.0\n 28.9\n Plt\n 85\n 90\n 84\n 109\n Creatinine\n 0.4\n TCO2\n 31\n Glucose\n 83\n Other labs: PT / PTT / INR:13.8/25.6/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:454 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.6\n mg/dL, Mg:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan:\n 64 yo f s/p mvc with mult R sided rib fxs, R chest tube and splenic lac\n s.p angio coiling but cont'd slow hct drop\n Neurologic: : Neuro checks Q:4 Pain: Aceaminophen 1000 mg po q 6 h, d/c\n fentanyl PCA-pain controlled percocets\n Cardiovascular: CV stable s/p cardio, s/p CEs neg x 3\n Pulmonary: Rt ptx s/p CT placement,O2 sats good on NC, CT to water\n seal: small PTX CXR :\n Gastrointestinal / Abdomen: extensive splenic lacs embolized by IR,+\n BM; ADAT to regular diet\n Renal: Foley, Cr 0.6 on admit, follow UOP\n Hematology: Stable\n Endocrine: RISS, cont thryroid supplement\n Infectious Disease: no issues, afebrile\n Lines / Tubes / Drains: PIV x3, foley, Rt CT, L radial art line\n Fluids: KVO\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: Arterial Line - 04:45 AM; 18 Gauge - 10:57\n AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full\n Disposition: Transfer to floor\n Total time spent: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2182-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 680092, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n PMH: hypothyroidism\n PSH: abdominoplasty\n : thyroid replacement\n Current medications:\n . Acetaminophen 3. Calcium Gluconate 4. Calcium Carbonate 5. Dapsone 6.\n Famotidine 7. Fentanyl PCA ; Percocet. Insulin 9. Lorazepam 10.\n Magnesium Sulfate 11. Metoclopramide 12. Potassium Chloride 13.\n Potassium Phosphate\n Thyroid\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:53 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: 37.2\nC (99\n HR: 77 (65 - 87) bpm\n BP: 161/82(115) {130/60(86) - 167/84(119)} mmHg\n RR: 19 (15 - 28) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82 kg (admission): 81 kg\n Total In:\n 2,448 mL\n 112 mL\n PO:\n 1,000 mL\n Tube feeding:\n IV Fluid:\n 1,448 mL\n 112 mL\n Blood products:\n Total out:\n 2,700 mL\n 652 mL\n Urine:\n 2,160 mL\n 592 mL\n NG:\n Stool:\n Drains:\n Balance:\n -252 mL\n -540 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.47/42/89.//6\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral , Diminished bases: ),\n Abdominal: Soft, Non-tender, Bowel sounds present, , mild distention\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 109 K/uL\n 10.0 g/dL\n 83 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.9 %\n 4.7 K/uL\n [image002.jpg]\n 01:44 PM\n 05:17 PM\n 08:38 PM\n 12:35 AM\n 04:59 AM\n 10:53 AM\n 11:01 AM\n 11:39 PM\n 05:04 AM\n 05:20 AM\n WBC\n 5.4\n 4.7\n Hct\n 28.7\n 28.8\n 29.3\n 27.1\n 27.3\n 27.4\n 26.9\n 29.0\n 28.9\n Plt\n 85\n 90\n 84\n 109\n Creatinine\n 0.4\n TCO2\n 31\n Glucose\n 83\n Other labs: PT / PTT / INR:13.8/25.6/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:454 mg/dL, Lactic Acid:2.7 mmol/L, Ca:7.6\n mg/dL, Mg:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan:\n 64 yo f s/p mvc with mult R sided rib fxs, R chest tube and splenic lac\n s.p angio coiling but cont'd slow hct drop\n Neurologic: : Neuro checks Q:4 Pain: Aceaminophen 1000 mg po q 6 h, d/c\n fentanyl PCA-pain controlled percocets\n Cardiovascular: CV stable s/p cardio, s/p CEs neg x 3\n Pulmonary: Rt ptx s/p CT placement,O2 sats good on NC, CT to water\n seal: small PTX CXR :\n Gastrointestinal / Abdomen: extensive splenic lacs embolized by IR,+\n BM; ADAT to regular diet\n Renal: Foley, Cr 0.6 on admit, follow UOP\n Hematology: Stable\n Endocrine: RISS, cont thryroid supplement\n Infectious Disease: no issues, afebrile\n Lines / Tubes / Drains: PIV x3, foley, Rt CT, L radial art line\n Fluids: KVO\n Consults: Trauma surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: Arterial Line - 04:45 AM; 18 Gauge - 10:57\n AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full\n Disposition: Transfer to floor\n Total time spent: 33 minutes\n" }, { "category": "Social Work", "chartdate": "2182-06-27 00:00:00.000", "description": "Social Work Admission Note", "row_id": 679367, "text": "Family Information\n Next of : \n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: (husband)\n Communication or visitation restriction: none\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: Pt is from , no\n previous admits at .\n Past psychiatric history: none known\n Past addictions history: none\n Employment status: unknown\n Legal involvement: none known\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Pt is 64 yr-old woman adm to TSICU s/p MVC\n in which she was belted passenger in car driven by her son that was\n by another car driven by a drunk driver. Another son who was\n other passenger is in TSICU also. Pt w/ abdominal injuries, liver lac.\n Met w/pt at bedside: she is A&Ox3, pleasant woman in bed wearing hard\n collar, c/o of pain & discomfort & asking about how her son is doing.\n She stated that she will be fine if her son is OK. She reports that she\n has 6 children (3 sons & 3 ) & 2 of her sons are here in .\n Son who was driving is graduating from Business School today\n and that is why pt and her husband are in . She spoke of how\n disappointed she feels for her sons and family in general as they had\n been looking forward to this day for a long time. Pt expecting her\n husband to visit soon and expressed some concern for son who was\n driving because she fears he will feel guilty.\n Pt is lovely, articulate woman who appears to be coping appropriately\n with aftermath of MVC. She does seem more concerned about her son than\n herself, but this is to be expected. Supportive family. SW provided\n emotional support & will continue to follow.\n Clergy Contact: Name: Pt is LDS, says her family will contact their\n here in .\n Communication with Team: Primary Nurse: \n / Follow up: SW will continue to follow and assess coping, provide\n support as needed. Please page PRN.\n , LICSW\n #\n" }, { "category": "Physician ", "chartdate": "2182-06-28 00:00:00.000", "description": "Intensivist Note", "row_id": 679461, "text": "SICU\n HPI:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n Chief complaint:\n Splenic las s/p embolization with Hct slowly trending down\n PMHx:\n PMH: hypothyroidism\n PSH: abdominoplasty\n : thyroid replacement\n Current medications:\n 1000 mL LR 3. 1000 mL LR 4. Acetaminophen 5. Calcium Gluconate 6.\n Famotidine 7. Fentanyl PCA\n 8. Insulin 9. Magnesium Sulfate 10. Metoclopramide 11. Ondansetron 12.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ANGIOGRAPHY - At 08:00 AM\n splenic angiogram\n Allergies:\n Gluten\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 02:00 PM\n Famotidine (Pepcid) - 08:23 PM\n Other medications:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.1\nC (98.8\n HR: 76 (49 - 87) bpm\n BP: 126/63(87) {80/44(57) - 143/72(96)} mmHg\n RR: 15 (14 - 35) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,884 mL\n 512 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,834 mL\n 512 mL\n Blood products:\n 1,050 mL\n Total out:\n 2,004 mL\n 205 mL\n Urine:\n 884 mL\n 165 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,880 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 129 K/uL\n 9.1 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 110 mEq/L\n 141 mEq/L\n 25.1 %\n 8.3 K/uL\n [image002.jpg]\n 04:16 AM\n 04:25 AM\n 12:31 PM\n 04:26 PM\n 08:09 PM\n 12:31 AM\n 04:05 AM\n WBC\n 11.2\n 11.2\n 8.3\n Hct\n 32.2\n 34\n 28.8\n 30.8\n 27.6\n 26.3\n 25.1\n Plt\n 137\n 168\n 129\n Creatinine\n 0.6\n 0.6\n 0.7\n 0.6\n Troponin T\n <0.01\n <0.01\n <0.01\n Glucose\n 167\n 159\n 145\n 117\n Other labs: PT / PTT / INR:14.0/22.2/1.2, CK / CK-MB / Troponin\n T:219/4/<0.01, Fibrinogen:172 mg/dL, Lactic Acid:2.7 mmol/L, Ca:6.8\n mg/dL, Mg:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PNEUMOTHORAX, TRAUMATIC, TRAUMA, S/P, ACUTE PAIN, .H/O HYPOTHYROIDISM\n Assessment and Plan:\n 64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .Neurologic: Neuro checks Q:4, C-collar until C-spine clear. f/u all CT\n scans (head, C-spine, Chest, abd, pelvis). Pain: Aceaminophen 1000 mg\n po q 6 h, fentanyl 25-100 mcg q 2 hr prn pain\n Cardiovascular: Stable\n Pulmonary: Rt ptx s/p CT placement, Resp- spon, O2 (placed on NRB by\n ED, wean as tol)\n Gastrointestinal / Abdomen: extensive splenic lacs, follow serial Hct,\n NPO; Splenic artery embolized\n Renal: Foley, Adequate UO, Required a couple of fluid boluses .\n Hematology: HEME: q 4 hr Hct drifting down to 25\n Endocrine: ENDO: RISS, check TSH, restart thyroid replacement\n Infectious Disease: No issues\n Lines / Tubes / Drains: PIV x3, foley, Rt CT, L radial art line\n Fluids: LR @ 80 ml/hr\n Consults: Trauma surgery\n Billing Diagnosis:\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: 16 Gauge - 04:40 AM\n Arterial Line - 04:45 AM\n 18 Gauge - 10:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2182-06-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 679596, "text": "64F s/p MVC frontseat passenger, with extensive splenic lacs, and rt\n anterior rib fx 2,3,4,5; Right ptx, RML lung contusion, left inf pelvic\n ramus ? stepoff; BP initially 120's in Ed, then drifted down to 70's;\n in ED rec'd 3 U PRBCs & 3 L crystalloid. Reported to be in Afib in ED\n but ECG looks like ST w/ PACs\n .\n Pneumothorax, traumatic\n Assessment:\n R CT to 20cm wall sxn. Sm crepidus at site, + fluctuation, occasional\n leak observed. Draining sm amts serosang. drainge. Weak non productive\n cough. Lungs clear and equal diminished bibasilar. O2 sats >93% on 3L\n NC.\n Action:\n CT dsg changed am. C/DB encouraged, IS teaching done.\n Response:\n CT maintained, insertion site WNl. Reaches 750 on IS.\n Plan:\n Follow CXRs, ? H20 seal tomorrow. Continue aggressive pulm .hygiene.\n Acute Pain\n Assessment:\n Reports R sided rib fxs as primary source of pain. Describes pain as\n dull/achey and 2 at best and 6 at worst with movement.\n Action:\n Fentanyl PCA 12.5mcg and 1gm Tylenol Q6.\n Response:\n Pt reports pain is well controlled.\n Plan:\n Continue to assess for pain, treat with Tylenol and consider weaning to\n PO analgesia or Morphine PCA.\n Trauma, s/p\n Assessment:\n Hct 24-25\n Action:\n Q4 hcts monitored\n Response:\n Hct stable.\n Plan:\n Serial Hcts\n .\n" }, { "category": "Nutrition", "chartdate": "2182-06-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 679583, "text": "Patient screened per ICU protocol. Patient has been NPO and/or on\n unsupplemented clear liquid diet for 1 day. If patient's diet is not\n able to be advanced and tolerated, for nutrition\n support. Patient S/P MVA with rib fx. Plan to advance diet. Will follow\n page with questions\n" }, { "category": "Nursing", "chartdate": "2182-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679449, "text": "Acute Pain\n Assessment:\n Complains of right chest and abdominal pain with movement or\n coughing or deep breathing\n Action:\n Fentanyl pca 12.5mcg\n Tylenol 1gm po\n Response:\n Pain at rest, tolerating turning, limited to bedrest for splenic\n fracture\n Plan:\n Continue to provide adequate analgesia to allow for pulmonary toileting\n Trauma, s/p\n Assessment:\n Hemodynamically stable. Low urine output as charted.\n Action:\n Q4 hct checks\n Total 1L LR bolus\n Response:\n Hct drifting slowly 27.6->25.1\n Urine output increased after fluid generally >20mL/hr which is\n acceptable MD\n Plan:\n Continue to monitor hemodynamics and fluid balance\n Continue q4 hematocrit checks\n Bedrest, IS, coughing and deep breathing\n" }, { "category": "Nursing", "chartdate": "2182-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679400, "text": "Acute Pain\n Assessment:\n Pt had c/o pain in her R chest at rest. With movement pain\n increases to .\n Action:\n Given fentanyl PRN with good effect though had periods of nausea,\n initial unclear if r/t fentanyl. Given zofran with little effect then\n regaln. Nausea resolved as dose of reglan being pushed. Later changed\n to PCA with dilaudid. After 2 doses she began feeling very uneasy and\n anxious, stating she\nhates the way this drug is making me feel, I just\n want to scream\n. Changed to fentanyl PCA. Tylenol 1 gram given po.\n Response:\n Pt reports good pain control, uses PCA appropriately and denies any\n further nausea.\n Plan:\n Continue current regimen. Pt may benefit from ATC Tylenol rather than\n PRN.\n Pneumothorax, traumatic\n Assessment:\n Pt has R sided CT to 20cmH2O. Serosang drainage in small amts. +\n airleak, -crepitus. Dressing D&I. Lung sounds clear with diminished\n bases and occ crackles.\n Action:\n Drainage amt monitored closely.\n Response:\n No intervention needed.\n Plan:\n Continue current POC.\n Trauma, s/p\n Assessment:\n Pt brought to angio this for splenic angiogram.\n Action:\n Large pseudo anuersym and multiple areas of distal bleeds seen.\n Pseudoanuersym coiled and no active bleeding seen post coiling. R\n Femoral Sheath removed and pt maintained bedrest/reverse T- til\n 1400. Continued serial HCTs.\n Response:\n HCT stable 28-30. No signs of active bleeding.\n Plan:\n Continue serial HCTs and close monitoring of VS.\n" }, { "category": "Radiology", "chartdate": "2182-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083634, "text": " 10:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: **TIME SENSITIVE, PLEASE PERFORM AT 2100**\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with known PTX, now s/p clamping of CT x 5 hours, assess for\n interval PTx prior to pull\n REASON FOR THIS EXAMINATION:\n **TIME SENSITIVE, PLEASE PERFORM AT 2100**\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Status post clamping of chest tube for five hours.\n\n FINDINGS: The right-sided chest tube is again visualized. No pneumothorax is\n identified. There continues to be a right effusion and left lower lung volume\n loss/infiltrate/effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2182-06-26 00:00:00.000", "description": "Report", "row_id": 241053, "text": "Sinus rhythm. Compared to the previous tracing cardiac rhythm is now sinus\nmechanism.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-06-26 00:00:00.000", "description": "Report", "row_id": 241054, "text": "Atrial fibrillation with a mean ventricular rate of 107. Borderline\nleft axis deviation. Possible left anterior fascicular block. No previous\ntracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2182-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083583, "text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for progression of pneumothorax; PLEASE DO AT 12 NO\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with chest tube to waterseal, history of recurrent\n pneumothorax\n REASON FOR THIS EXAMINATION:\n evaluate for progression of pneumothorax; PLEASE DO AT 12 NOON, TIME SENSITIVE\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Chest tube on waterseal in a patient with recurrent\n pneumothorax.\n\n Portable AP chest radiograph was compared to prior study obtained on at 7:42 p.m.\n\n The current study demonstrates unchanged appearance of the right pigtail\n catheter with minimal left apical pneumothorax. The left retrocardiac\n atelectasis and right basal atelectasis are unchanged. There is no interval\n development of new areas of consolidation, edema, or increase in pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1082627, "text": " 11:08 AM\n CHEST (PA & LAT) Clip # \n Reason: interval evaluation of chest tube after clamping.\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with right rib fractures and chest tube which has been\n clamped\n REASON FOR THIS EXAMINATION:\n interval evaluation of chest tube after clamping.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMS: PA and lateral chest \n\n INDICATION: Right chest tube clamped.\n\n FINDINGS: Comparison is made to 08:53.\n\n The right chest tube remains in place at the lung base. Right pneumothorax\n has increased in size, now moderate. Left pleural effusion and retrocardiac\n atelectasis is unchanged. Cardiomediastinal contours are stable.\n\n IMPRESSION: Increased right pneumothorax, now moderate in size.\n\n Findings were paged to at 11:25 on .\n\n\n" }, { "category": "Radiology", "chartdate": "2182-07-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1082994, "text": " 8:37 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for interim changes\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with known PTX, Chest tube leak\n REASON FOR THIS EXAMINATION:\n assess for interim changes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow-up of a patient with known pneumothorax.\n\n PA and lateral upright chest radiograph was compared to as well\n as prior x-rays from .\n\n Compared to the most recent radiograph, the right pneumothorax appears to be\n increased, which is currently mild to moderate but when compared to the PA and\n lateral view obtained on , at 11:10 a.m., the pneumothorax is not\n significantly different. That raises an option that positioning difference\n influences the appearence of the pneumothoraxand should be taken into\n account and repeated radiograph in about four hours in upright position with\n PA and lateral technique is highly recommended for the assessment of the\n dynamics of the pneumothorax. Findings were discussed with Dr. \n over the phone by Dr. at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2182-06-27 00:00:00.000", "description": "MOD SEDATION, EACH ADDL 15 MIN.", "row_id": 1081919, "text": " 7:52 AM\n ABDOMINAL AORTA Clip # \n Reason: splenic extravasation on CT, pls angio & embolize\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n Contrast: VISAPAQUE Amt: 95\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO 3ED ORDER /BRACHIOCEPHALIC *\n * 1SR ORDER /BRACHIOCEPHALIC -59 DISTINCT PROCEDURAL SERVICE *\n * ADD'L 2ND/3RD OR> /BRACHIO ADD'L 2ND/3RD OR> /BRACHIO *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * EA ADD'L VESSEL AFTER BASIC A- EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 yo s/p MVC w/ extensive splenic lacs\n REASON FOR THIS EXAMINATION:\n splenic extravasation on CT, pls angio & embolize\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMPd 1:46 PM\n PFI: Celiac and splenic arteriogram demonstrating multiple distal\n pseudoaneurysms throughout the spleen with no active extravasation. The\n largest proximal pseudoaneurysm measured approximately 6 x 7 mm and was coil\n embolized to stasis. If the patient becomes hemodynamically unstable, we can\n repeat the procedure with embolization with Gelfoam.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 64-year-old woman status post MVC with extensive\n splenic lacerations and intraperitoneal hemorrhage. A recent CT scan\n demonstrates active extravasation versus pseudoaneurysm in the spleen. Request\n is made for splenic arteriogram with possible embolization.\n\n FELLOW: Dr. .\n\n RESIDENT: .\n\n STAFF RADIOLOGIST: Dr. who supervised the procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n a total of 200 mcg of fentanyl throughout the total intraservice time of 3\n (Over)\n\n 7:52 AM\n ABDOMINAL AORTA Clip # \n Reason: splenic extravasation on CT, pls angio & embolize\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n Contrast: VISAPAQUE Amt: 95\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hours 10 minutes during which the patient's hemodynamic parameters were\n continuously monitored. 1% lidocaine was used for local anesthesia.\n\n PROCEDURES:\n 1. Celiac, splenic, and three selective fourth order branch of the splenic\n artery angiograms, along with follow up post post-embolization angiogram.\n 2. Distal splenic artery pseudoaneurysm embolization.\n\n FINDINGS: After review of the risks and benefits of the procedure as well as\n conscious sedation, informed consent was obtained. The patient was brought to\n the angiography suite and placed supine on the imaging table. The right groin\n was prepped and draped in the usual sterile fashion. Access was obtained into\n the right common femoral artery with a 19-gauge single wall needle through\n which wire was passed into the abdominal aorta. The needle was\n replaced with a 5 French vascular sheath which was attached to sidearm flush.\n catheter was advanced over the wire and used to select the celiac\n trunk.\n\n A celiac arteriogram was performed which demonstrated opacification of the\n common hepatic artery, the left gastric artery, and the splenic artery and its\n branches. There are innumerable distal small splenic pseudoaneurysms\n throughout the spleen. There is no active extravasation. The largest\n pseudoaneurysm is more proximal to the splenic hilum and measures 6 x 7 mm. A\n Glidewire was advanced into the splenic artery. The catheter was\n exchanged for a 4 French C2 catheter which was advanced into the splenic\n artery itself more distally.\n\n A splenic arteriogram was performed which again demonstrated the innumerable\n small pseudoaneurysms and the larger more proximal pseudoaneurysm. Again, no\n active extravasation was seen.\n\n Using a Renegade STC microcatheter and a 016 Fathom wire, access was obtained\n beyond the lower pole smaller branch of the splenic artery into the upper pole\n branch. From here, three separate fourth order branches were selected in turn\n and arteriograms were performed in each one. This is in the region of the mid\n portion of the spleen.\n\n The middle branch of these three demonstrated filling of a pseudoaneurysm\n arising from it. Access was obtained into this 4th order middle branch beyond\n the stalk of the pseudoaneurysm. Coils were deployed. The catheter was\n pulled back proximal to the stalk of the pseudoaneurysm. Again, coils were\n deployed. A total of seven 2 mm x 1 cm Cook Hilal coils were deployed.\n\n A follow up post post-embolization arteriogram from this middle fourth order\n branch demonstrated no significant flow within the branch and the\n (Over)\n\n 7:52 AM\n ABDOMINAL AORTA Clip # \n Reason: splenic extravasation on CT, pls angio & embolize\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n Contrast: VISAPAQUE Amt: 95\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pseudoaneurysm was no longer visualized. Given the patients hemodynamic\n stability and the lack of active extravasation on angiogram the decision was\n made not to proceed with non selective gelfoam embolization of the main upper\n and middle pole splenic artery at this time. The cathether and microcatheter\n were removed and the right common femoral arteriotomy site was closed with a 6\n french angioseal device after confirming appropriate common femoral artery\n puncture.\n\n IMPRESSION:\n 1. Celiac, splenic, and selective fourth order splenic artery branch\n arteriograms performed demonstrating numerous small distal pseudoaneurysms\n throughout the spleen and a larger 6 mm x 7 mm pseudoaneurysm closer to the\n splenic hilum.\n 2. Successful coil embolization of the proximal splenic pseudoaneurysm to\n stasis.\n\n PLAN: The coil embolization was performed to reduce the risk of delayed\n rupture of the pseudoaneurysm. It was felt that the risks of Gelfoam\n embolization at this point outweigh the potential benefits given that the\n patient was hemodynamically stable. If the patient develops hemodynamic\n instability, we can repeat the angiogram and perform nonselective Gelfoam\n embolization of the splenic artery.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2182-07-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1083689, "text": " 10:58 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p pull of CT with known leak\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS.\n\n HISTORY: Chest tube with known leak. Question pneumothorax.\n\n FINDINGS: There are bilateral effusions, left greater than right, with left\n lower lobe dense retrocardiac opacification consistent with volume loss and\n infiltrate. No pneumothorax is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1081884, "text": " 11:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p mva\n REASON FOR THIS EXAMINATION:\n ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:27 AM\n No intracranial hemorrhage or fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head are obtained at 5-mm section\n thickness with 2.5 mm bone algorithm reconstructions and multiplanar\n reformatted images.\n\n FINDINGS: There is no intracranial hemorrhage, shift of normally midline\n structures, or evidence of acute major vascular territorial infarct. -\n white matter differentiation is preserved. The calvaria is intact. There is\n pansinus mucosal thickening, most prominent in the right maxillary sinus. The\n imaged portion of the mastoid air cells are well aerated.\n\n IMPRESSION:\n\n 1. No intracranial hemorrhage or fracture.\n\n 2. Pansinus mucosal thickening.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082713, "text": " 5:23 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate placement\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p pullback of chest tube\n REASON FOR THIS EXAMINATION:\n evaluate placement\n ______________________________________________________________________________\n WET READ: JXKc MON 10:12 PM\n Right chest tube tip overlies right lower lung medially. Small right\n pneumothorax is unchanged. Left retrocardiac opacity likely reflects\n atelectasis and moderate left pleural effusion. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow-up of a patient with right chest tube pulled\n back in the presence of pneumothorax.\n\n Portable AP chest radiograph was compared to obtained at 3:09\n p.m.\n\n The right apical pneumothorax is unchanged or minimally increased, still\n small. The position of the right chest tube is slightly more distal. The\n left retrocardiac atelectasis accompanied by moderate pleural effusion is\n unchanged. The cardiomediastinal silhouette is stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081996, "text": " 1:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess PTX\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with MVC\n REASON FOR THIS EXAMINATION:\n Assess PTX\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 2:40 PM\n PFI: No reoccurrence of pneumothorax. Chest tube in unchanged position\n including sharp kink. Right mid lung field contusion beginning to clear up\n already. No new abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: Status post MVC. Assess pneumothorax.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position, and analysis is performed in direct comparison with a\n preceding similar study obtained approximately 11 hours earlier during the\n same day. Position of the previously identified chest tube is unaltered, and\n this includes the described sharp kink at the level of the most proximal side\n port. The previously described diffuse parenchymal density in the right lung\n mid portion shows already some regress, and this corresponds to the CT\n identified area of contusion in the right middle lobe. The tiny pneumothorax\n separation that was identified on the previous study is now not seen anymore.\n No new parenchymal abnormalities are identified.\n\n IMPRESSION: No reoccurrence of pneumothorax. Pulmonary contusion density in\n right mid lung field demonstrating partial regression. No new abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081997, "text": ", E. TSICU 1:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess PTX\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with MVC\n REASON FOR THIS EXAMINATION:\n Assess PTX\n ______________________________________________________________________________\n PFI REPORT\n PFI: No reoccurrence of pneumothorax. Chest tube in unchanged position\n including sharp kink. Right mid lung field contusion beginning to clear up\n already. No new abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082689, "text": " 2:43 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for interim PTX\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p placement back on suction\n REASON FOR THIS EXAMINATION:\n eval for interim PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST, \n\n INDICATION: Pneumothorax, reevaluation status post chest tube placed back to\n suction.\n\n FINDINGS: Comparison made to , 11:10.\n\n Right chest tube is unchanged in position. Right apical pneumothorax has\n decreased in the interval, now small in size. Left pleural effusion and\n retrocardiac atelectasis remain stable. Cardiomediastinal contours are\n unchanged.\n\n IMPRESSION: Decrease in size of now small right pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-07-03 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1083043, "text": " 12:57 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for dynamics of pneumothorax; please do at 1pm, **\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with known PTX\n REASON FOR THIS EXAMINATION:\n assess for dynamics of pneumothorax; please do at 1pm, **TIME SENSITIVE**\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST :\n\n HISTORY: Pneumothorax. Assess size.\n\n IMPRESSION: PA and lateral chest compared to 8:30 a.m. today:\n\n Right pneumothorax has nearly resolved, and basal pleural tubes still in\n place, probably fissural. Moderate left pleural effusion stable. No left\n pneumothorax. Heart size stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-27 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1081894, "text": " 2:45 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for free fluid in abdomen\n Field of view: 40 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with spleen trauma\n REASON FOR THIS EXAMINATION:\n evaluate for free fluid in abdomen\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:41 AM\n Interval development of large hemoperitoneum with extensive splenic\n lacerations. A few small splenic pseudoaneurysms with concern for active\n bleeding from an anterior splenic pseudoaneurysm.\n\n Perhaos slight increase in size of right basilar pneumothorax. Right middle\n lobe contusion and bibasilar consolidations again noted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: CT torso, at 00:05.\n\n TECHNIQUE: Contrast-enhanced axial images of the abdomen and pelvis were\n obtained with multiplanar reformatted images. 70 cc of IV Optiray contrast\n was administered uneventfully.\n\n FINDINGS: A right basilar pneumothorax demonstartes mild increase in size\n compared to the initial CT. A chest tube is partially imaged. Bibasilar lung\n opacities and right middle lobe consolidation are again noted.\n\n The liver, pancreas, adrenal glands remain unremarkable. The kidneys enhance\n symmetrically and excrete contrast normally without hydronephrosis or\n hydroureter. Hypodense bilateral renal lesions are unchanged in the short\n interval.\n\n A moderate amount of high density free fluid in the abdomen has developed in\n the short interval, with a large amount around the spleen. Multiple\n lacerations in the spleen are again identified, a few of which demonstrate\n expanding contrast collections on delayed images consistent with active\n extravasation.\n\n Intra-abdominal loops of large and small bowel are of normal caliber and there\n is no pneumoperitoneum or evidence for obstruction.\n\n CT PELVIS WITH CONTRAST: The rectum and sigmoid colon are unremarkable. The\n bladder contains a Foley. A large amount of hemoperitoneum is present in the\n pelvis.\n\n Bone windows reveal no change in the short interval.\n\n IMPRESSION:\n (Over)\n\n 2:45 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for free fluid in abdomen\n Field of view: 40 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Interval development of large hemoperitoneum with large lacerations as well\n as foci of active extravasation in the spleen. Findings discussed with Dr.\n shortly after study performed and posted to ED dashbaord.\n\n 2. Mild increase in the size of a right basilar pneumothorax with new chest\n tube, partially imaged. Right middle lobe contusion and bibasilar\n consolidations again noted.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1083172, "text": " 8:56 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate changes\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with interval increased PTX and chest tube to suction\n REASON FOR THIS EXAMINATION:\n evaluate changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation of interval changes.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the extent of the minimal\n right-sided pneumothorax is unchanged. Also unchanged is the course and\n position of the right-sided chest tube. No signs of tension, unchanged left\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-26 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1081883, "text": " 11:15 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p mva\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n TRAUMA CHEST: Widening of the upper mediastinum represents prominent\n vasculature in junction with recent CT. Heart size may be mildly enlarged.\n Signs of volume overload include prominent azygous vein and hilar fullness.\n There is no definite effusion, and right basilar pneumothorax is\n inconspicuous, as are the bibasilar consolidations and right middle lobe\n contusion.\n\n TRAUMA PELVIS: There is no fracture or dislocation. The sacroiliac joints\n and pubic symphysis are preserved.\n\n IMPRESSION:\n 1. Volume overload. Right basilar pneumothorax and lung consolidations are\n inconspicuous.\n 2. No pelvic fracture.\n\n" }, { "category": "Radiology", "chartdate": "2182-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082410, "text": " 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube placed to waterseal. Want an interval evaluation\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM\n\n Findings were discussed with Dr. over the phone by Dr. at\n the time of dictation.\n\n\n 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube placed to waterseal. Want an interval evaluation\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p MVC. Who had a chest tube placed for pneumothorax\n REASON FOR THIS EXAMINATION:\n chest tube placed to waterseal. Want an interval evaluation\n ______________________________________________________________________________\n WET READ: JMGw SAT 6:22 PM\n right chest tube unchanged. no pneumothorax. increasing left pleural effusion.\n increased retrocardiac consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with chest tube on waterseal.\n\n Portable AP chest radiograph was compared to prior study from .\n\n The right chest tube is unchanged in position. There is right apical\n pneumothorax demonstrated, small, with apical and basal component. It appears\n to be increased since study obtained at 1:58 p.m., but unchanged\n compared to study obtained at 02:27 a.m. There is worsening of\n the left basal opacity consistent with atelectasis accompanied by pleural\n effusion, but pneumonia at this area cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083466, "text": " 7:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluation\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p placement of pigtail placement and removal of chest tube\n REASON FOR THIS EXAMINATION:\n evaluation\n ______________________________________________________________________________\n WET READ: YMf FRI 9:06 PM\n No increase in size of right apical pneumothorax. Bilateral effusions stable.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after placement of PICC\n catheter and removal of the chest tube.\n\n Portable AP chest radiograph was compared to prior study obtained on at 10:47 a.m.\n\n The current study that was obtained with portable technique demonstrates\n minimal right apical pneumothorax. The right chest tube has been removed. The\n pigtail catheter has been placed in the interim. The left basal opacity and\n pleural effusions are unchanged and the left upper lung is unremarkable.\n\n IMPRESSION:\n Interval removal of the right chest tube replaced by the pigtail catheter.\n The right apical pneumothorax appears to be smaller, which also might be at\n least partially related to the portable and not through upright technique.\n Thus, repeated evaluation with PA and lateral radiographs is highly\n recommended for precise evaluation of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082866, "text": " 11:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with right chest tube\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the right chest tube position and\n pneumothorax.\n\n Portable AP chest radiograph was compared to obtained at 5:37\n p.m.\n\n The right chest tube is in unchanged position. There is interval significant\n decrease in the pneumothorax which is currently minimal restricted to the very\n apex of the lung. Bilateral pleural effusions left more than right and left\n retrocardiac atelectasis is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-27 00:00:00.000", "description": "ADD'L 2ND/3RD OR> THOR/BRACHIOCEPHALIC", "row_id": 1081920, "text": ", E. TSICU 7:52 AM\n ABDOMINAL AORTA Clip # \n Reason: splenic extravasation on CT, pls angio & embolize\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n Contrast: VISAPAQUE Amt: 95\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 yo s/p MVC w/ extensive splenic lacs\n REASON FOR THIS EXAMINATION:\n splenic extravasation on CT, pls angio & embolize\n ______________________________________________________________________________\n PFI REPORT\n PFI: Celiac and splenic arteriogram demonstrating multiple distal\n pseudoaneurysms throughout the spleen with no active extravasation. The\n largest proximal pseudoaneurysm measured approximately 6 x 7 mm and was coil\n embolized to stasis. If the patient becomes hemodynamically unstable, we can\n repeat the procedure with embolization with Gelfoam.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083645, "text": " 2:39 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: time sensitive, please perform at 0300\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p pull of chest tube\n REASON FOR THIS EXAMINATION:\n time sensitive, please perform at 0300\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Status post pull-up chest tube.\n\n FINDINGS: The right-sided chest tube has been removed. There is a tiny right\n apical pneumothorax. Again seen is a small right effusion and volume\n loss/infiltrate/effusion in the left lower lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-07-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1083193, "text": " 10:25 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n Reason: evaluate tube placement and parenchymal lung injury\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with known chest tube and persistant leak, ? chest tube\n placement\n REASON FOR THIS EXAMINATION:\n evaluate tube placement and parenchymal lung injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:12 PM\n 1. Small right basilar pneumothorax which has significantly decreased in size\n since prior study. The right chest tube enters into the major fissure and\n also kinks on itself at the confluence of the major and minor fissure best\n seen on series 105 image 38 and series 3 image 26.\n\n 2. New small left pleural effusion.\n\n 3. Status post embolization of the spleen with residual large subcapsular\n hematoma and a small 4-mm pseudoaneurysm noted in one of the lacerations.\n\n 4. Interval decrease in the size of hemoperitoneum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman with known chest tube and persistent leak.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE: Axial MDCT images of the chest and abdomen were obtained after\n administration of 100 cc of Optiray intravenously. Sagittal and coronal\n reformatted images were then obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: Multiple pathologically enlarged\n mediastinal nodes are noted. For example the right hilar node measures 15 mm\n in short axis. The anterior subcarinal node measures 11 mm. The aorta and\n great vessels have normal appearance. No pericardial effusion is noted. Small\n left pleural effusion. Mild bibasilar atelectasis. Small basilar pneumothorax\n on the right side. The right-sided chest tube enters into the major fissure\n and kinks on itself at the confluence of the major and minor fissure.\n This is best seen on series 105 image 38 and series 3 image 26.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder, adrenal glands,\n pancreas appear normal. Both kidneys contain small hypodense lesions which\n are too small to characterize. The spleen contains a large subcapsular\n hematoma measuring approximately 4.9 x 8.8 cm. The patient is status post\n embolization of the splenic artery. Multiple foci of laceration are noted\n within the spleen. 5-mm round blush is noted into one of the areas of\n laceration best seen on series 3 image 52. Hematoma is noted adjacent to the\n spleen and liver and gallbladder bed which has decreased its density since\n prior study. Stomach, duodenum, loops of small bowel and large bowel appear\n unremarkable.\n (Over)\n\n 10:25 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n Reason: evaluate tube placement and parenchymal lung injury\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n\n 1. Small right basilar pneumothorax which has significantly decreased in size\n since prior study. The right chest tube kinks on itself inthe major fissure.\n\n 2. New small left pleural effusion.\n\n 3. Status post embolization of the spleen with residual large subcapsular\n hematoma and a small 5-mm pseudoaneurysm in one of the lacerations.\n\n 4. Interval decrease in the size of hemoperitoneum.\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081892, "text": " 2:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: stat please s/p chest tube placement please evaluate placeme\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 yo F s/p trauma\n REASON FOR THIS EXAMINATION:\n stat please s/p chest tube placement please evaluate placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, status post chest tube placement.\n\n AP CHEST: A new right chest tube is likely intrafissural, with a sharp kink\n at the level of the most proximal sideport. Right middle lobe contusion and\n basilar consolidation, as seen on the recent CT, is noted. The right basilar\n pneumothorax and effusions are evident. Basilar consolidation is also present\n on the left. Volume overload has improved. There is no significant short\n interval change in the widened appearance of the mediastinum, secondary to\n vascular prominence in conjunction with recent CT. Cardiac silohuette is\n unchanged. Nondisplaced right rib fractures are more conspicuous on CT.\n\n IMPRESSION:\n 1. Intrafissural right chest tube with sharp kink at proximal sideport. Right\n basilar hemopneumothorax.\n 2. Right middle lobe contusion with with bibasilar consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-04 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 1083194, "text": ", E. CC6A 10:25 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n Reason: evaluate tube placement and parenchymal lung injury\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with known chest tube and persistant leak, ? chest tube\n placement\n REASON FOR THIS EXAMINATION:\n evaluate tube placement and parenchymal lung injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Small right basilar pneumothorax which has significantly decreased in size\n since prior study. The right chest tube enters into the major fissure and\n also kinks on itself at the confluence of the major and minor fissure best\n seen on series 105 image 38 and series 3 image 26.\n\n 2. New small left pleural effusion.\n\n 3. Status post embolization of the spleen with residual large subcapsular\n hematoma and a small 4-mm pseudoaneurysm noted in one of the lacerations.\n\n 4. Interval decrease in the size of hemoperitoneum.\n\n" }, { "category": "Radiology", "chartdate": "2182-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083609, "text": " 4:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PLEASE PERFORM AT 16:15 --time sensitive\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p clamping of chest tube\n REASON FOR THIS EXAMINATION:\n PLEASE PERFORM AT 16:15 --time sensitive\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Clamping of the chest tube.\n\n Portable AP chest radiograph was compared to obtained at 11:58\n a.m.\n\n The right pigtail catheter is in unchanged position. There is no evidence of\n pneumothorax. Cardiomediastinal silhouette is stable and there is no change\n in the left retrocardiac opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082460, "text": " 8:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess CT on water seal\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with MVC\n REASON FOR THIS EXAMINATION:\n assess CT on water seal\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the chest tube on the water seal.\n\n Portable AP chest radiograph was compared to prior study from .\n\n Small right apical pneumothorax is unchanged. The position of the right chest\n tube is unchanged as well. The cardiomediastinal silhouette is stable. There\n is no change in the left retrocardiac consolidation consistent with a\n combination of atelectasis and pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-07-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1083385, "text": " 10:44 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for progression of pneumothorax\n Admitting Diagnosis: S/O MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with chest tube and leak\n REASON FOR THIS EXAMINATION:\n eval for progression of pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST :\n\n HISTORY: Chest tubes and possible leak.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small right apical pneumothorax has increased. Right pleural tube is sharply\n folded and may be bent to the point of occlusion and probably cannulates the\n right major fissure.\n\n Left lower lobe atelectasis, moderate left pleural effusion, stable. Heart\n size is normal.\n\n Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1081886, "text": " 11:28 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p mva\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:13 AM\n No fracture. Cervical spondylosis without listhesis. Tiny left apical\n pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old female status post trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the cervical spine are obtained with\n multiplanar reformatted images.\n\n FINDINGS: There is no fracture or acute alignment abnormality. The\n atlantoaxial and atlanto-occipital articulations are maintained. Vertebral\n body heights are maintained, and there is no prevertebral soft tissue\n swelling. There is multilevel cervical spondylosis, with the most prominent\n disc height narrowing noted at C3/4 and C5/6. Subchondral sclerosis and small\n anterior and posterior osteophytes are noted at these levels. Mild osteophytic\n narrowing involves the left neural foramen at C5/6.\n\n The imaged portions of the mastoid air cells are well aerated. Bilateral\n maxillary sinus mucosal thickening is partially imaged. A tiny pneumothorax\n is noted at the right lung apex.\n\n IMPRESSION:\n 1. No fracture or acute alignment abnormality.\n\n 2. Cervical spondylosis, most prominent at C3/4 and C5/6.\n\n 3. Tiny right apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-06-26 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1081887, "text": " 11:29 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MV\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p mva\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n WET READ: 12:37 AM\n Small right anterior pneumothorax with tiny right pleural effussion.\n Moderatley large right middle lobe contusion with right basilar\n atelectasis/aspiration. 2nd05th right rib nondisplaced anterior fractures.\n\n Multiple large splenic lacerations. Irregular intrasplenic hyperdense\n collections may represent pseudoaneurysm vs foci of active bleeding. No\n perisplenic hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced axial images of the chest, abdomen, and pelvis\n were obtained with multiplanar reformatted images.\n\n CT CHEST WITH CONTRAST: The heart and great vessels are unremarkable and\n there is no evidence for pericardial or pleural effusion. Small right\n paratracheal lymph nodes measure up to 8 mm, which does not meet CT criteria\n for pathologic enlargement. There is no evidence for pericardial effusion.\n\n A small right pneumothorax is most prominent along the anteroinferior\n hemithorax with a small amount of pleural fluid noted posteriorly. Mixed-\n density consolidation is present in the right middle lobe with bibasilar,\n right greater than left, consolidation. The airways are patent to the\n subsegmental level bilaterally.\n\n CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, and adrenal\n glands appear normal. There are multiple large splenic lacerations, several\n of which demonstrate irregular contrast collections within. No perisplenic\n free fluid is seen.\n\n The kidneys enhance symmetrically and excrete contrast normally. Bilateral\n hypoattenuating renal lesions are too small to characterize but likely\n represent cysts. There is no hydronephrosis or hydroureter. Intra-abdominal\n loops of large and small bowel are of normal caliber, and there is no\n pneumoperitoneum or free fluid. The abdominal aorta is of normal caliber. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes are\n identified.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid colon are unremarkable. The\n (Over)\n\n 11:29 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MV\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bladder is moderately distended. There is no free pelvic fluid.\n\n Bone windows reveal non-displaced right second through fifth rib fractures,\n anteriorly. Subcutaneous emphysema overlies the fracture anteriorly.\n\n IMPRESSION:\n 1. Small right hydropneumothorax. Nondisplaced right anterior second through\n fifth rib fractures.\n 2. Right middle lobe contusion with right greater than left basilar opacity\n representing atelectasis versus aspiration.\n 3. Multiple large splenic lacerations. Irregular round and linear\n intrapslenic contrast collections are concerning for active extravasation,\n however, no perisplenic hematoma is identified.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394650, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with PCA dilaudid on arrival, rated pain with after self\n administered bolus dilaudid. After 3-4 hrs, Pt c/o right groin spasms\n , screaming out in pain and crying, refused repositoning d/t fear\n of more pain, increased attempts and injections of PCA with transient\n effect. + CSM right foot, dsg D&I, Hct stable 28.9, no S/S bleeding\n into thigh\n Action:\n Surgery contact for input by HO, ativan .25 mg IV x 2 for spasms with\n no effect. Increased dose of dilaudid from .12mg q 6min->>.25 mg q 6\n min. Warm packs to right groin. Finally, Valium 2.5 mg IV x 2\n Response:\n Valium effective for relaxation, able to get pt to cooperate with\n repositioning to right side and he has settled out, now rates pain \n as an acceptable level\n Plan:\n PCA dilaudid as ordered. Pt responded well to valium, would use again\n if needed. Reposition. Monitor CSM, dsg right leg, hip precautions.\n Emotional support.\n Hypotension (not Shock)\n Assessment:\n Neo gtt @ 0.5 mcg on arrival. A&O x 3, follows commands. NSR 80s-90s.\n Pt likes to hold arm with aline over his head or on abdomen giving\n false low so NBP cuff placed as back-up which correlated with\n aline. UOP<5cc/hr clear yellow urine. Taking PO fluids.\n Action:\n LR 250cc over 1 hr x 5 (1250cc). Foley irrigated without incident.\n Weaning neo slightly. Will transfuse 1 unit PRBC for Hct 27 from 29\n Response:\n A&O x 3. Continues with neo gtt @ 0.3mcg with ABP 90s-100s/. UOP\n picking up, now ~>30cc/hr x 3 hrs.\n Plan:\n Transfuse I unit PRBC, monitor UOP and BP, wean off neo as tolerated.\n Enc full liquid diet.\n" }, { "category": "ECG", "chartdate": "2145-11-02 00:00:00.000", "description": "Report", "row_id": 158020, "text": "Sinus rhythm. Diffuse low voltage is diminished as compared with previous\ntracing of . There is baseline artifact. Prior infero-posterior\nmyocardial infarction. Otherwise, no diagnostic interim change. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 394673, "text": "TITLE: resident progress note\n Chief Complaint: Hypotension after hip arthroplasty\n 24 Hour Events:\n - 250cc boluses given attempting to increase UOP\n - Increased dilaudid PCA due to right groin pain and spasms\n - Gave two doses IV lorazepam and two doses IV diazepam\n - Noted Cr rise to 3.5 and HCT decrease to 27\n - Sent urine lytes when enough urine produced and FeNa = 0.18%\n - Transfused one unit PRBC at 0600\n ARTERIAL LINE - START 08:00 PM\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Vancomycin - 05:56 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Diazepam (Valium) - 02:35 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 07:26 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: 91 (81 - 92) bpm\n BP: 96/57(69) {78/45(56) - 121/59(76)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 1,514 mL\n PO:\n 500 mL\n TF:\n IVF:\n 572 mL\n 1,381 mL\n Blood products:\n 4,875 mL\n 133 mL\n Total out:\n 2,095 mL\n 212 mL\n Urine:\n 20 mL\n 142 mL\n NG:\n Stool:\n Drains:\n 80 mL\n 70 mL\n Balance:\n 3,852 mL\n 1,302 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n GENERAL: NAD aside from occasional right groin pain\n HEENT: PERRL, EOMI, no conjunctival pallor, no scleral icterus, oral\n mucosa and lips extremely dry\n NECK: Supple, No LAD, No thyromegaly, no JVP elevation\n CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G\n LUNGS: attenuated and decreased anterior breath sounds with basilar\n crackles noted at midaxillary line bilaterally and anterior, unable to\n obtain posterior exam due to patient positioning\n ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic\n EXTREMITIES: Trace bipedal edema, compression stockings and pneumoboots\n in place, right hip with large C/D/I bandage overlying, right thigh\n soft though tender in right groin area, bilateral radial pulses and\n hand cap refill preserved\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout.\n Labs / Radiology\n 199 K/uL\n 9.4 g/dL\n 161 mg/dL\n 3.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 95 mg/dL\n 96 mEq/L\n 134 mEq/L\n 27.0 %\n 23.0 K/uL\n [image002.jpg]\n Hct on admission 30.4, Crt 2.8\n 10:36 PM\n 03:50 AM\n WBC\n 23.0\n Hct\n 28.9\n 27.0\n Plt\n 199\n Cr\n 3.5\n Glucose\n 161\n Other labs: PT / PTT / INR:13.1/26.8/1.1, Differential-Neuts:90.7 %,\n Lymph:5.4 %, Mono:3.3 %, Eos:0.3 %, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.2 mg/dL\n Assessment and Plan\n 67 yo M with complicated past medical history who had an elective total\n right hip arthroplasty earlier today.\n #. Post-Operative Hypotension: Has required phenlylephrine and has had\n low urine output. Given 250cc bolus of LR x 4. Likely is\n intravascularly depleted despite lots of intraoperative fluids. Likely\n is third spacing and probably has some blood loss with the procedure.\n Also has diastolic heart failure and needs close weight/fluid balance\n monitoring.\n - Wean from phenylephrine as tolerated\n - Serial HCT to assure no ongoing or acute blood loss\n - Track urine output\n - Consider ECHO to assess for any changes in cardiac function from\n prior\n - Hold home furosemide, losartan pending improvement in blood pressure\n .\n #. Post-op course: Patient overall well controlled with only occasional\n bouts of right groin pain.\n - Appreciate surgery input for all post-op managment decisions\n - Vancomycin Q12H for two doses for prophylaxis\n - Drain care and dressing changes per surgery\n - Dilaudid PCA overnight\n - Low dose lorazepam for spasms\n .\n #. Diabetes mellitus:\n - Diabetic diet\n - QID fingersticks\n - Glargine 18 units QHS and humalog sliding scale\n .\n #. OSA:\n - Continue nightly home BiPAP at IPAP=16 and EPAP=13 with 4L oxygen\n .\n #. Chronic diastolic CHF:\n - Monitor volume status with rehydration. Use small boluses to avoid\n volume overload.\n - Daily weights\n - Hold furosemide until hypotension resolves\n .\n #. Chronic kidney disease:\n - Monitor post-op creatinine.\n - Avoid nephrotoxic agents.\n - Renally dose medications.\n .\n FEN:\n .\n -Pain management with dilaudid PCA\n .\n ICU Care\n Nutrition: Full liquid diabetic diet, advance as tolerated to regular\n diabetic diet\n Glycemic Control: Insulin Sliding scale\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT: Enoxaparin Sodium 40 mg SC Q24H\n Stress ulcer: Pantoprazole\n VAP: None\n Comments:\n Communication: Comments: wife, \n Code status: Full code\n Disposition: ICU today\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 394681, "text": "Chief Complaint: Hypotension--post operative\n S/P Total Hip Replacement\n Congestive Heart 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 Overnight--patient with SBP=90--with wide range\n He had slow improvement in urine flow with small volume fluid bolus\n -Patient noted some persistent groin pain overnight--left side\n -1 unit PRBC this morning\n -Patient with ongoing thirst\n 24 Hour Events:\n ARTERIAL LINE - START 08:00 PM\n History obtained from Medical records\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Vancomycin - 08:12 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Pantoprazole (Protonix) - 08:11 AM\n Diazepam (Valium) - 08:11 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 Constitutional: Fatigue, No(t) Fever, T=99.5\n Cardiovascular: No(t) Chest pain\n Musculoskeletal: Joint pain, in region of hip repair\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Pain: Mild\n Flowsheet Data as of 09:40 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: 36.7\nC (98.1\n HR: 86 (81 - 92) bpm\n BP: 115/55(75) {71/39(49) - 121/59(76)} mmHg\n RR: 19 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 2,063 mL\n PO:\n 500 mL\n 120 mL\n TF:\n IVF:\n 572 mL\n 1,606 mL\n Blood products:\n 4,875 mL\n 337 mL\n Total out:\n 2,095 mL\n 292 mL\n Urine:\n 20 mL\n 222 mL\n NG:\n Stool:\n Drains:\n 80 mL\n 70 mL\n Balance:\n 3,852 mL\n 1,771 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: Thin\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)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\nwarm and with boots and stockings in place\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 9.4 g/dL\n 199 K/uL\n 161 mg/dL\n 3.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 95 mg/dL\n 96 mEq/L\n 134 mEq/L\n 27.0 %\n 23.0 K/uL\n [image002.jpg]\n 10:36 PM\n 03:50 AM\n WBC\n 23.0\n Hct\n 28.9\n 27.0\n Plt\n 199\n Cr\n 3.5\n Glucose\n 161\n Other labs: PT / PTT / INR:13.1/26.8/1.1, Differential-Neuts:90.7 %,\n Lymph:5.4 %, Mono:3.3 %, Eos:0.3 %, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.2 mg/dL\n Fluid analysis / Other labs: FeNA=0.12%\n Microbiology: No data\n Assessment and Plan\n 67 yo male with a history of CHF, DM, chronic renal failure, OSA,\n fibrothorax and s/p decortication now with admission following right\n total hip arthroplasty in the setting of significant post operative\n hypotension. This was requiring neo for support in the PACU setting\n and with history of CHF and need for significant fluid support patient\n to ICU for further care. His hypotension did appear to be related to\n hypovolemic shock with blood loss and small volume support with fluid\n bolus.\n 1)Hypotension--Likely related to some relative hypovolemia and\n vasodilatory effects of pain medications. He has had some persistent\n hypotension despite positive fluid balance and has required\n neosynephrine support overnight. WBC count is elevated significantly\n but we have seen minimal fevers to date which would make argument for\n vasodilatory shock less likely.\n -We do have clear evidence of a lung exam with minimal crackles this\n morning. He had no tachypnea despite pain at this time. He has\n signficant thirst this morning\n -Will provide volume with 500cc NS this morning given 250cc well\n tolerated\n -We do have minor improvement in urine output through to this morning\n and neo dosing as we go forward and will wean to off\n -If unable to wean at this time will have to consider central line and\n alternative pressor and central monitoring\n -Will send cultures for all bacterial pathogens given rising WBC count\n if fever seen\nwill consider antibiotics for clear fever and suspicious\n source but at this time\nwe do not have significant fever.\n 2)Sleep Apnea-\n -Will continue with BIPAP\n 3)S/P hip repair-\n -Vanco given x 2 doses post operatively\n -Follow HCT\n -Follow hip exam\n -Drain in place\n -Incentive spirometry 10x/hr while awake\n -Will use anxiolytics and pain medications in combination\n 4)Renal Failure\nChronic and history of significant edema has been seen\n in the past with persistent creatinine elevation\n -Follow urine output\n -Significant pre-renal insult at this time given urine lytes findings\n -Follow up lytes\n -Has pre-renal picture\n ICU Care\n Nutrition: PO intake\nclear liquids\n Glycemic Control:\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 394712, "text": "TITLE: resident progress note\n Chief Complaint: Hypotension after hip arthroplasty\n 24 Hour Events:\n - 250cc boluses given attempting to increase UOP\n - Increased dilaudid PCA due to right groin pain and spasms\n - Gave two doses IV lorazepam and two doses IV diazepam\n - Noted Cr rise to 3.5 and HCT decrease to 27\n - Sent urine lytes when enough urine produced and FeNa = 0.18%\n - Transfused one unit PRBC at 0600\n ARTERIAL LINE - START 08:00 PM\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Vancomycin - 05:56 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Diazepam (Valium) - 02:35 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 07:26 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: 91 (81 - 92) bpm\n BP: 96/57(69) {78/45(56) - 121/59(76)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 1,514 mL\n PO:\n 500 mL\n TF:\n IVF:\n 572 mL\n 1,381 mL\n Blood products:\n 4,875 mL\n 133 mL\n Total out:\n 2,095 mL\n 212 mL\n Urine:\n 20 mL\n 142 mL\n NG:\n Stool:\n Drains:\n 80 mL\n 70 mL\n Balance:\n 3,852 mL\n 1,302 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n GENERAL: NAD aside from occasional right groin pain\n HEENT: PERRL, EOMI, no conjunctival pallor, no scleral icterus, oral\n mucosa and lips extremely dry\n NECK: Supple, No LAD, No thyromegaly, no JVP elevation\n CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G\n LUNGS: attenuated and decreased anterior breath sounds with basilar\n crackles noted at midaxillary line bilaterally and anterior, unable to\n obtain posterior exam due to patient positioning\n ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic\n EXTREMITIES: Trace bipedal edema, compression stockings and pneumoboots\n in place, right hip with large C/D/I bandage overlying, right thigh\n soft though tender in right groin area, bilateral radial pulses and\n hand cap refill preserved\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout.\n Labs / Radiology\n 199 K/uL\n 9.4 g/dL\n 161 mg/dL\n 3.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 95 mg/dL\n 96 mEq/L\n 134 mEq/L\n 27.0 %\n 23.0 K/uL\n [image002.jpg]\n Hct on admission 30.4, Crt 2.8\n 10:36 PM\n 03:50 AM\n WBC\n 23.0\n Hct\n 28.9\n 27.0\n Plt\n 199\n Cr\n 3.5\n Glucose\n 161\n Other labs: PT / PTT / INR:13.1/26.8/1.1, Differential-Neuts:90.7 %,\n Lymph:5.4 %, Mono:3.3 %, Eos:0.3 %, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.2 mg/dL\n Assessment and Plan\n 67 yo M with complicated past medical history who had an elective total\n right hip arthroplasty yesterday.\n #. Post-Operative Hypotension: Has required phenlylephrine and has had\n low urine output. Given 250cc bolus of LR x 4. Likely is\n intravascularly depleted despite lots of intraoperative fluids. Likely\n is third spacing and probably has some blood loss with the procedure.\n Also has diastolic heart failure and needs close weight/fluid balance\n monitoring.\n - Wean from phenylephrine as tolerated\n - Will give additional 500cc bolus of LR at this time\n - Serial HCT to assure no ongoing or acute blood loss\n - Track urine output\n - Consider ECHO to assess for any changes in cardiac function from\n prior\n - Hold home furosemide, losartan pending improvement in blood pressure\n .\n #. Post-op course: Patient overall well controlled with only occasional\n bouts of right groin pain.\n - Appreciate surgery input\n - Vancomycin Q12H for two doses for prophylaxis completed\n - Drain care and dressing changes per surgery\n - Dilaudid PCA overnight, will switch to po dilaudid today\n - Low dose lorazepam or valium for spasms\n .\n #. Acute on chronic kidney failure: Creatinine increased to 3.5 today\n from baseline of 2.8, urine lytes consistent with prerenal etiology.\n Will continue to track creatinine.\n - Monitor post-op creatinine.\n - Avoid nephrotoxic agents.\n - Renally dose medications.\n - Give IVF as above\n .\n #. Leukocytosis: Likely post-op reaction, but could be related to\n underlying infection.\n - Will send urine analysis and culture today\n - Blood culture if spikes fever\n - Consider C Diff although doesn\nt have risk factors\n - Incentive spirometer at bedside\n .\n #. Diabetes mellitus:\n - Diabetic diet\n - QID fingersticks\n - Glargine 18 units QHS and humalog sliding scale\n .\n #. OSA:\n - Continue nightly home BiPAP at IPAP=16 and EPAP=13 with 4L oxygen\n .\n #. Chronic diastolic CHF:\n - Monitor volume status with rehydration. Use small boluses to avoid\n volume overload.\n - Daily weights\n - Hold furosemide until hypotension resolves\n ICU Care\n Nutrition: Full liquid diabetic diet, advance as tolerated to regular\n diabetic diet\n Glycemic Control: Insulin Sliding scale\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT: Enoxaparin Sodium 30 mg SC Q24H, have decreased dose due to renal\n function\n Stress ulcer: Pantoprazole\n VAP: None\n Comments:\n Communication: Comments: wife, \n Code status: Full code\n Disposition: ICU today\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 394758, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p r hip arthroplasty. R hip drsg d&I without drainage. Hemovac\n drained 50cc\ns blood. Received on dilaudid pca without basal rate. Pt\n yelling out and moaning in pain that increased in intensity with any\n nursing care that was never totally relieved with pca pain control.\n Positive csm to right foot.\n Action:\n Suregery by to evalauate pt. dilaudid pca d/c\nd and changed to po\n dilaudid. Medicated x2 with 2.5 mg ivp valium for ? anxiety component\n that might have intensified the level of his pain. Hemovac drsg d/c\n by surgery. Pt consulted for increase in activity. Pt repositioned\n from side to side. Once pca pump was d/c\nd pt was medicated with 2 mg\n po dilaudid.\n Response:\n R hip drsg &i. wife in to visit and pt no longer yelling out\n or moaning in pain. Appears more comfortable than this am,\n Plan:\n Plan is for r hip drsg be changed by surgery in the am. Will\n continue to medicate with po dilaudid as needed for pain control.\n Increase pt\ns level of activity as per recs of physical therapy.\n Monitor csm to r lower extremity. Emotional support to pt and his wife.\n Hypotension (not Shock)\n Assessment:\n Received pt on neogtt at 0.5mcg/kg/min which needed to be increased for\n a short period of time to 0.7mcg/kg/min. to maintain map>60 or sbp>\n 90. lower than nbp cuff. Adequate hourly uo continues.\n Hypotension most likely due to being intravascularly depleted despite\n lots of ivf intraoperatively.\n Action:\n Pt transfused with 2^nd unit of prbc\ns. neo gtt weaned to off. Given\n 500cc bolus of rl. Repeat hct sent off. Hemodynamics and uo followed\n closely.\n Response:\n Now with adequate hourly uo. Sbp now > 90 off pressors.\n Plan:\n If uo drops off or sbp drops below 90 will consider additional boluses\n of ivf. Follow hcts as ordered and transfuse prbc\ns as needed.\n Demographics\n Attending MD:\n K.\n Admit diagnosis:\n RIGHT HIP OA/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 118 kg\n Daily weight:\n Allergies/Reactions:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n Precautions:\n PMH: Anemia, COPD, Diabetes - Insulin\n CV-PMH: CHF, Hypertension, PVD\n Additional history: OSA-- uses home CPAP, polyneuropathy, CKD--cr\n 2.4-2.8\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:54\n Temperature:\n 99\n Arterial BP:\n S:102\n D:42\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 90 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 3,211 mL\n 24h total out:\n 712 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:56 PM\n Potassium:\n 4.2 mEq/L\n 02:56 PM\n Chloride:\n 98 mEq/L\n 02:56 PM\n CO2:\n 28 mEq/L\n 02:56 PM\n BUN:\n 95 mg/dL\n 02:56 PM\n Creatinine:\n 3.2 mg/dL\n 02:56 PM\n Glucose:\n 162 mg/dL\n 02:56 PM\n Hematocrit:\n 28.3 %\n 11:43 AM\n Finger Stick Glucose:\n 161\n 12:00 PM\n Valuables / Signature\n Patient valuables: glasses, walker and cane\n Other valuables: clothes transferred with pt\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: 406\n Transferred to: 1269\n Date & time of Transfer: 1800\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394759, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p r hip arthroplasty. R hip drsg d&I without drainage. Hemovac\n drained 50cc\ns blood. Received on dilaudid pca without basal rate. Pt\n yelling out and moaning in pain that increased in intensity with any\n nursing care that was never totally relieved with pca pain control.\n Positive csm to right foot.\n Action:\n Suregery by to evalauate pt. dilaudid pca d/c\nd and changed to po\n dilaudid. Medicated x2 with 2.5 mg ivp valium for ? anxiety component\n that might have intensified the level of his pain. Hemovac drsg d/c\n by surgery. Pt consulted for increase in activity. Pt repositioned\n from side to side. Once pca pump was d/c\nd pt was medicated with 2 mg\n po dilaudid.\n Response:\n R hip drsg &i. wife in to visit and pt no longer yelling out\n or moaning in pain. Appears more comfortable than this am,\n Plan:\n Plan is for r hip drsg be changed by surgery in the am. Will\n continue to medicate with po dilaudid as needed for pain control.\n Increase pt\ns level of activity as per recs of physical therapy.\n Monitor csm to r lower extremity. Emotional support to pt and his wife.\n Hypotension (not Shock)\n Assessment:\n Received pt on neogtt at 0.5mcg/kg/min which needed to be increased for\n a short period of time to 0.7mcg/kg/min. to maintain map>60 or sbp>\n 90. lower than nbp cuff. Adequate hourly uo continues.\n Hypotension most likely due to being intravascularly depleted despite\n lots of ivf intraoperatively.\n Action:\n Pt transfused with 2^nd unit of prbc\ns. neo gtt weaned to off. Given\n 500cc bolus of rl. Repeat hct sent off. Hemodynamics and uo followed\n closely.\n Response:\n Now with adequate hourly uo. Sbp now > 90 off pressors.\n Plan:\n If uo drops off or sbp drops below 90 will consider additional boluses\n of ivf. Follow hcts as ordered and transfuse prbc\ns as needed.\n" }, { "category": "Rehab Services", "chartdate": "2145-11-03 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 394763, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: hip OA / 715.95\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 67yoM c h/o L THA in\n ? c continued worsening of L hip pain and decreased activity level.\n R hip imaged and found to have significant hip OA as well. Pt admit for\n R THA performed yesterday . Post-op c/b hypotension & decreased\n urine output requiring transfer to ICU.\n Past Medical / Surgical History: Urinary retention, CRI, BPH, anemia,\n MRSA, anxiety/depression, thoracotomy and lung decortication c trach\n (), s/p ccy (), s/p L THA (?), patellar surgery, s/p appy,\n CAD s/p NSTEMI (), CHF, cardiomyopathy, DM, sleep apnea\n Medications: oxycodone, insulin, glucagon, lactulose, lasix, vanco,\n albuterol inhaler\n Radiology: hip xray: s/p THA\n Labs:\n 28.3\n 9.4\n 199\n 23.0\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c assist, posterior hip precautions\n Social / Occupational History: lives c wife, retired\n Environment: 3 stairs to enter single level home (Pt has not\n been using stairs - walking around), shower chair, raised toilet seat,\n sock aide\n Prior Functional Status / Activity Level: Indep amb c rollator, also\n has RW, + falls LLE instability, wife assist c donning R sock\n Objective Test\n Arousal / Attention / Cognition / Communication: A&Ox3, pleasant,\n cooperative, appropriate, receptive but c marked anxiety about movement\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 99\n 106/54\n 26\n 100% 4L\n Rest\n /\n Sit\n 101\n 81/49\n 31\n 90%-98% 4L\n Activity\n /\n Stand\n /\n Recovery\n 95\n 98/45\n 33\n 100% 4L\n Total distance walked: N/A\n Minutes:\n Pulmonary Status: Lung sounds c bilateral basilar crackles, o/w CTA but\n diminished, no cough noted or reported, supplemental O2 via nasal\n cannula, increased WOB c + accessory muscle use and increased RR c\n activity and anxiety\n Integumentary / Vascular: PIV, foley, tele, dressing CD&I, + palp DP\n Sensory Integrity: c/o baseline neuropathy numbness/tingling below\n knees bilat but intact to light touch\n Pain / Limiting Symptoms: at rest, c activity, c ROM\n (all pain in R hip but mostly R groin)\n Posture: obese, forward head posturing\n Range of Motion\n Muscle Performance\n BUEs WFL\n R hip flex 76, IR 25, ER 10, Abd 6\n o/w BLEs WFL\n BUEs >/= \n LLE >/= \n R hip flex 2-/5, R hip abd >/=\n B DF \n Motor Function: able to isolate all muscle groups, no tremors noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: HOB elevated ~45 deg, use of bed rail for bed\n mobility\n 2 people utilized but Pt able to perform c Mod A\n Max verbal cueing for proper technique\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\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: Sitting eob progresses from min A to S x5 minutes c BUE\n support on bed.\n Education / Communication: c MD re: activity orders; c RN re:\n pt status and plan of care; Pt and wife educated e re: role and goal of\n PT, post hip precautions, therex, DB/PLB, relaxation techniques, plan\n of care and d/c planning\n Intervention: Supine therex RLE reps each\n Diagnosis:\n 1.\n Joint Mobility, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Muscle Performace, Impaired\n 4.\n Range of Motion, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 67yoM s/p R THA now POD #1 seen in ICU\n issues c hypotension and decreased urine output. Pt displays the\n above impairments c/w bony surgery. He is most limited by pain and\n anxiety. It is expected that c increased activity, pain control,\n continued PT intervention, Pt may be able to progress to safe level for\n d/c to home in more sessions however, post-op complications and\n presentation today Pt is aware that rehab may be recommended for\n optimal recovery of independent function prior to home.\n Goals\n Time frame: 2-3 sessions\n 1.\n Independent bed mobility\n 2.\n Sit-stand and transfer c RW independently\n 3.\n Amb 150' c RW independently\n 4.\n Independent in HEP\n 5.\n Independent maintenance of post hip precautions c all activity\n 6.\n >/= 92% SaO2 c all activity and stable HDR c all activity\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: 2-3 sessions/ 1 week\n bed mobility, transfer and gait training\n therex, ROM\n Pt education\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face Time: 17:05-17:40\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394621, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with PCA dilaudid on arrival, rated pain with after self\n administered bolus dilaudid. After 3-4 hrs, Pt c/o right groin spasms\n , screaming out in pain and crying, refused repositoning d/t fear\n of more pain, increased attempts and injections of PCA with transient\n effect. + CSM right foot, dsg D&I, Hct stable 28.9, no S/S bleeding\n into thigh\n Action:\n Surgery contact for input by HO, ativan .25 mg IV x 2 for spasms with\n no effect. Increased dose of dilaudid from .12mg q 6min->>.25 mg q 6\n min. Warm packs to right groin. Finally, Valium 2.5 mg IV x 2\n Response:\n Valium effective for relaxation, able to get pt to cooperate with\n repositioning to right side and he has settled out, now rates pain \n as an acceptable level\n Plan:\n PCA dilaudid as ordered. Pt responded well to valium, would use again\n if needed. Reposition. Monitor CSM, dsg right leg, hip precautions.\n Emotional support.\n Hypotension (not Shock)\n Assessment:\n Neo gtt @ 0.5 mcg on arrival. A&O x 3, follows commands. NSR 80s-90s.\n Pt likes to hold arm with aline over his head or on abdomen giving\n false low so NBP cuff placed as back-up which correlated with\n aline. UOP<5cc/hr clear yellow urine. Taking PO fluids.\n Action:\n LR 250cc over 1 hr x 4. Foley irrigated without incident. Unable to\n titrate neo gtt off\n Response:\n A&O x 3. Continues with neo gtt @ 0.5mcg. UOP still<5cc/hr.\n Plan:\n Will continue with gentle fluid boluses per team, monito UOP and BP,\n wean off neo as tolerated. Enc full liquid diet.\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394622, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with PCA dilaudid on arrival, rated pain with after self\n administered bolus dilaudid. After 3-4 hrs, Pt c/o right groin spasms\n , screaming out in pain and crying, refused repositoning d/t fear\n of more pain, increased attempts and injections of PCA with transient\n effect. + CSM right foot, dsg D&I, Hct stable 28.9, no S/S bleeding\n into thigh\n Action:\n Surgery contact for input by HO, ativan .25 mg IV x 2 for spasms with\n no effect. Increased dose of dilaudid from .12mg q 6min->>.25 mg q 6\n min. Warm packs to right groin. Finally, Valium 2.5 mg IV x 2\n Response:\n Valium effective for relaxation, able to get pt to cooperate with\n repositioning to right side and he has settled out, now rates pain \n as an acceptable level\n Plan:\n PCA dilaudid as ordered. Pt responded well to valium, would use again\n if needed. Reposition. Monitor CSM, dsg right leg, hip precautions.\n Emotional support.\n Hypotension (not Shock)\n Assessment:\n Neo gtt @ 0.5 mcg on arrival. A&O x 3, follows commands. NSR 80s-90s.\n Pt likes to hold arm with aline over his head or on abdomen giving\n false low so NBP cuff placed as back-up which correlated with\n aline. UOP<5cc/hr clear yellow urine. Taking PO fluids.\n Action:\n LR 250cc over 1 hr x 4. Foley irrigated without incident. Unable to\n titrate neo gtt off\n Response:\n A&O x 3. Continues with neo gtt @ 0.5mcg with ABP 90s-100s/. UOP\n still<5cc/hr.\n Plan:\n Will continue with gentle fluid boluses per team, monitor UOP and BP,\n wean off neo as tolerated. Enc full liquid diet.\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394620, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with PCA dilaudid on arrival, rated pain with after bolused with\n dilaudid. Pt c/o right groin spasms, refused repositoing\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n A&O x 3, follows commands. NSR 80s-90s. Pt likes to hold arm with aline\n over his giving false low so NBP cuff placed as back-up.\n UOP<5cc/hr clear yellow urine\n Action:\n LR 250cc over 1 hr x 4. Foley irrigated without incident\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 394608, "text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67M underwent R hip arhtroplasty today, received IVF intraop, lost\n 600cc blood. In PACU, became hypotensive, given i U PRBCs. Hct measured\n at 30, down from 34. Given neosynephrine.\n Patient is without complaints other than mild hip discomfort.\n 24 Hour Events:\n History obtained from housestaff\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Other medications:\n Changes to medical and family history:\n DM\n CRI creatinine in mid-2's\n OSA on bipap\n CHF - diastolic\n right fibrothorax s/p decortication (? due to remote hemothorax)\n CCY\n appy\n left knee and hip replacements\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 Musculoskeletal: Joint pain\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 12:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 92 (81 - 92) bpm\n BP: 100/43(56) {88/20(42) - 106/66(72)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 19 mL\n PO:\n 500 mL\n TF:\n IVF:\n 572 mL\n 19 mL\n Blood products:\n 4,875 mL\n Total out:\n 2,095 mL\n 30 mL\n Urine:\n 20 mL\n 30 mL\n NG:\n Stool:\n Drains:\n 80 mL\n Balance:\n 3,852 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n 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 Abdominal: Non-tender, Distended\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 2.8\n 28.9 %\n [image002.jpg]\n 10:36 PM\n Hct\n 28.9\n ECG: NSR 81, no ischemia, low-volatage, no change\n Assessment and Plan\n hypotension s/p R hip arthroplasty - likely a consequence of volume\n depletion, will continue with as needed IVF, follow Hct and transfuse\n if falls further, wean pressors as needed. No strong need to work-up MI\n or PE for now.\n DM - on insulin\n OSA - continue bipap\n HTN / CHF - hold outpatient regimen for now\n pain control - PCA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 394609, "text": "Chief Complaint: Hypotension following hip arthroplasty\n HPI:\n 67 yo M with complicated past medical history who had an elective total\n right hip arthroplasty earlier today. During the surgery he received\n 3500 mL of crystalloid and had 965 mL of UOP. He was reported to have\n an EBL of 600 mL. He was noted to be hypotensive in the PACU following\n the operation and was given a single unit of PRBC with little effect on\n blood pressure. His HCT was measured as 30.4 after that unit of blood\n (down from baseline HCT of 33.8 pre-op). Additionally, patient had very\n low urine output of < 5 mL/hr. He was placed on phenylephrine\n peripherally to support his blood pressure and a transfer to the ICU\n was requested. The PACU anesthesia attending was concerned about fluid\n status and possibility of volume overload given that patient is an\n extremely difficult intubation and has required fiberoptic intubation\n in the past.\n ROS:\n (+)ve: fatigue, right groin pain, dry mouth, hunger\n (-)ve: fever, chills, sweats, chest pain, palpitations, orthopnea,\n paroxysmal nocturnal dyspnea, constipation, diarrhea, sore throat,\n myalgias, nausea, vomiting\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 12:11 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 92 (81 - 92) bpm\n BP: 100/43(56) {88/20(42) - 106/66(72)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 17 mL\n PO:\n 500 mL\n TF:\n IVF:\n 572 mL\n 17 mL\n Blood products:\n 4,875 mL\n Total out:\n 2,095 mL\n 30 mL\n Urine:\n 20 mL\n 30 mL\n NG:\n Stool:\n Drains:\n 80 mL\n Balance:\n 3,852 mL\n -13 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 28.9 %\n [image002.jpg]\n \n 2:33 A12/1/ 10:36 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 28.9\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 394610, "text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67M underwent R hip arhtroplasty today, received IVF intraop, lost\n 600cc blood. In PACU became hypotensive, given 1 U PRBCs. Hct measured\n at 30, down from 34. Given neosynephrine.\n Patient is without complaints other than mild hip discomfort.\n History obtained from housestaff\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Other medications:\n Changes to medical and family history:\n DM\n CRI creatinine in mid-2's\n OSA on bipap\n CHF - diastolic\n right fibrothorax s/p decortication (? due to remote hemothorax)\n CCY\n appy\n left knee and hip replacements\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 Musculoskeletal: Joint pain\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 12:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 92 (81 - 92) bpm\n BP: 100/43(56) {88/20(42) - 106/66(72)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 19 mL\n PO:\n 500 mL\n TF:\n IVF:\n 572 mL\n 19 mL\n Blood products:\n 4,875 mL\n Total out:\n 2,095 mL\n 30 mL\n Urine:\n 20 mL\n 30 mL\n NG:\n Stool:\n Drains:\n 80 mL\n Balance:\n 3,852 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese, comfortable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Non-tender, Distended\n Skin: warm extremities\n R hip dressed, no obvious hematoma, tender right groin\n Pressure stalking and pneumoboots on\n Neurologic: Attentive, alert and oriented\n Labs / Radiology\n 2.8\n 28.9 %\n [image002.jpg]\n 10:36 PM\n Hct\n 28.9\n ECG: NSR 81, no ischemia, low-volatage, no change\n Assessment and Plan\n hypotension s/p R hip arthroplasty - likely a consequence of volume\n depletion, will continue with as needed IVF, follow Hct and transfuse\n if falls further, wean pressors as tolerated. No strong need to work-up\n MI or PE for now.\n DM - on insulin\n OSA - continue bipap\n HTN / CHF - hold outpatient regimen for now\n pain control - PCA\n ICU Care\n Nutrition: can take PO\n Glycemic Control:\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 394611, "text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67M underwent R hip arhtroplasty today, received IVF intraop, lost\n 600cc blood. In PACU became hypotensive, given 1 U PRBCs. Hct measured\n at 30, down from 34. Given neosynephrine.\n Patient is without complaints other than mild hip discomfort.\n History obtained from housestaff\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown; Halluc\n Ms Contin (Oral) (Morphine Sulfate)\n Confusion/Delir\n Gabapentin\n extremities \n dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Enoxaparin (Lovenox) - 11:17 PM\n Other medications:\n Changes to medical and family history:\n DM\n CRI creatinine in mid-2's\n OSA on bipap\n CHF - diastolic\n right fibrothorax s/p decortication (? due to remote hemothorax)\n CCY\n appy\n left knee and hip replacements\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 Musculoskeletal: Joint pain\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 12:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 92 (81 - 92) bpm\n BP: 100/43(56) {88/20(42) - 106/66(72)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,947 mL\n 19 mL\n PO:\n 500 mL\n TF:\n IVF:\n 572 mL\n 19 mL\n Blood products:\n 4,875 mL\n Total out:\n 2,095 mL\n 30 mL\n Urine:\n 20 mL\n 30 mL\n NG:\n Stool:\n Drains:\n 80 mL\n Balance:\n 3,852 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese, comfortable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Non-tender, Distended\n Skin: warm extremities\n R hip dressed, no obvious hematoma, tender right groin\n Pressure stalking and pneumoboots on\n Neurologic: Attentive, alert and oriented\n Labs / Radiology\n 2.8\n 28.9 %\n [image002.jpg]\n 10:36 PM\n Hct\n 28.9\n ECG: NSR 81, no ischemia, low-volatage, no change\n Assessment and Plan\n hypotension s/p R hip arthroplasty - likely a consequence of volume\n depletion, will continue with as needed IVF, follow Hct and transfuse\n if falls further, wean pressors as tolerated. No strong need to work-up\n MI or PE for now.\n DM - on insulin\n OSA - continue bipap\n HTN / CHF - hold outpatient regimen for now\n pain control - PCA\n ICU Care\n Nutrition: can take PO\n Glycemic Control:\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 394612, "text": "Chief Complaint: Hypotension following hip arthroplasty\n HPI:\n 67 yo M with complicated past medical history who had an elective total\n right hip arthroplasty earlier today. During the surgery he received\n 3500 mL of crystalloid and had 965 mL of UOP. He was reported to have\n an EBL of 600 mL. He was noted to be hypotensive in the PACU following\n the operation and was given a single unit of PRBC with little effect on\n blood pressure. His HCT was measured as 30.4 after that unit of blood\n (down from baseline HCT of 33.8 pre-op). Additionally, patient had very\n low urine output of < 5 mL/hr. He was placed on phenylephrine\n peripherally to support his blood pressure and a transfer to the ICU\n was requested. The PACU anesthesia attending was concerned about fluid\n status and possibility of volume overload given that patient is an\n extremely difficult intubation and has required fiberoptic intubation\n in the past.\n ROS:\n (+)ve: fatigue, right groin pain, dry mouth, hunger\n (-)ve: fever, chills, sweats, chest pain, palpitations, orthopnea,\n paroxysmal nocturnal dyspnea, constipation, diarrhea, sore throat,\n myalgias, nausea, vomiting\n Allergies:\n Vicodin - Hallucinations\n Morphine Sulfate - Confusion/Delir\n Gabapentin - Extremities shake\n TRANSFER MEDICATIONS:\n 1) HYDROmorphone (Dilaudid) 0.12 mg IV PCA\n 2) Phenylephrine 0.5-5 mcg/kg/min IV DRIP\n 3) Vancomycin 1000 mg IV Q 12H for 2 doses post-op\n 4) Fluticasone Propionate NASAL 1 SPRY NU \n 5) Enoxaparin Sodium 40 mg SC Q24H\n 6) Pramipexole *NF* 0.125 mg Oral QD\n 7) LaMOTrigine 225 mg PO DAILY\n 8) Tamsulosin 0.4 mg PO HS\n 9) Losartan Potassium 50 mg PO DAILY\n 10) Furosemide 80 mg PO BID:PRN edema\n 11) Ipratropium Bromide MDI 2 PUFF IH Q 8H\n 12) Lactulose 30 mL PO/NG DAILY\n 13) Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n 14) Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n 15) Insulin SC (per Insulin Flowsheet)\n 16) Ondansetron 4 mg IV Q8H:PRN nausea/vomiting\n 17) DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis\n 18) Zolpidem Tartrate 2.5-5 mg PO QHS:PRN Insomnia\n 19) Promethazine 12.5-25 mg IV Q6H:PRN nausea\n 20) Milk of Magnesia 30 ml PO BID:PRN Constipation\n 21) Senna 1 TAB PO BID:PRN Constipation\n 22) Bisacodyl 10 mg PO/PR DAILY:PRN Constipation\n 23) Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q6H:PRN\n Dyspepsia\n 24) Docusate Sodium 100 mg PO BID\n 25) Pantoprazole 40 mg PO Q24H\n 26) OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain\n 27) BiPAP I=16, E=13, supplemental oxygen=4L\n Past medical history:\n Social History:\n 1) Diabetes mellitus II c/b neuropathy, nephropathy, retinopathy\n 2) Chronic diastolic CHF\n 3) Chronic kidney disease (baseline Cr 2.4 - 2.8)\n 4) OSA (Mask Choice: Swift II NV, DME Ordered: BiPAP 16/13; EERS\n 100, 4L O2)\n 5) Polyneuropathy (hand and feet)\n 6) Spinal stenosis\n 7) Severe degenerative arthritis\n 8) Anemia of chronic disease\n 9) Chronic restrictive ventilatory disease due to bile leak resulting\n in pulmonary fibrothorax requiring decortication\n 10) PVD w/ lower extremity claudication\n 11) Benign prostatic hyperplasia\n 12) Glaucoma; on carbonic anhydrase inhibitor\n 13) Bilateral cataracts s/p surgical removal\n 14) Depression\n 15) Erectile dysfunction s/p penile implant \n Surgical History:\n 1) Roux-en-y reconstruction after laparoscopic cholecystectomy c/b\n damage to CBD\n 2) decortication for fibrothorax complicated by respiratory\n failure requiring tracheostomy\n 3) Appendectomy\n 4) Left knee/hip replacement\n 5) L shoulder AC resection\n Patient lives with his wife. Former manager at Polaroid and then was a\n sports referee for many years. He is essentially independent in his\n daily activities, though needs some help getting dressed with certain\n clothing items. Has not driven in 6 years.\n Tobacco: Denies any history\n EtOH: 2-3 beers per month\n Illicits: Denies any history\n Family History:\n Brother-, h/o several strokes.\n Mother-dead in 70s from breast cancer.\n Father-dead at 61 from complications of emphysema, CHF.\n All children in good health.\n Physical Examination\n VS: T 97.8, HR 87, BP 91/56, RR 12, O2Sat 100% 2L NC\n GENERAL: NAD aside from occasional right groin pain\n HEENT: PERRL, EOMI, no conjunctival pallor, no scleral icterus, oral\n mucosa and lips extremely dry\n NECK: Supple, No LAD, No thyromegaly, no JVP elevation\n CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G\n LUNGS: attenuated and decreased anterior breath sounds with basilar\n crackles noted at midaxillary line bilaterally and anterior, unable to\n obtain posterior exam due to patient positioning\n ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic\n EXTREMITIES: Trace bipedal edema, compression stockings and pneumoboots\n in place, right hip with large C/D/I bandage overlying, right thigh\n soft though tender in right groin area, bilateral radial pulses and\n hand cap refill preserved\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 01:22PM\n 18.4*#\n 3.40*\n 10.7*\n 30.4*\n 89\n 31.4\n 35.2*\n 13.7\n 220\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [2] 01:22PM\n 230*\n 92*\n 2.8*\n 138\n 3.9\n 100\n 28\n 14\n CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n [3] 01:22PM\n 8.2*\n 5.4*#[1]\n 2.2\n TTE (Complete) :\n Conclusions\n The left atrium is elongated. Left ventricular wall thickness, cavity\n size and regional/global systolic function are normal (LVEF >55%).\n There is no ventricular septal defect. Right ventricular chamber size\n and free wall motion are normal. The diameters of aorta at the sinus,\n ascending and arch levels are normal. The aortic valve leaflets (3) are\n mildly thickened but aortic stenosis is not present. No aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. There is at least mild pulmonary\n artery systolic hypertension (TR spectral signal poor quality). There\n is no pericardial effusion.\n CARDIAC PERFUSION PERSANTINE :\n IMPRESSION:\n New partially reversible mild perfusion defect in the inferolateral\n wall without associated wall motion abnormality. EF 74%.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_4%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_6%22);\n" }, { "category": "Physician ", "chartdate": "2145-11-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 394613, "text": "Chief Complaint: Hypotension following hip arthroplasty\n HPI:\n 67 yo M with complicated past medical history who had an elective total\n right hip arthroplasty earlier today. During the surgery he received\n 3500 mL of crystalloid and had 965 mL of UOP. He was reported to have\n an EBL of 600 mL. He was noted to be hypotensive in the PACU following\n the operation and was given a single unit of PRBC with little effect on\n blood pressure. His HCT was measured as 30.4 after that unit of blood\n (down from baseline HCT of 33.8 pre-op). Additionally, patient had very\n low urine output of < 5 mL/hr. He was placed on phenylephrine\n peripherally to support his blood pressure and a transfer to the ICU\n was requested. The PACU anesthesia attending was concerned about fluid\n status and possibility of volume overload given that patient is an\n extremely difficult intubation and has required fiberoptic intubation\n in the past.\n ROS:\n (+)ve: fatigue, right groin pain, dry mouth, hunger\n (-)ve: fever, chills, sweats, chest pain, palpitations, orthopnea,\n paroxysmal nocturnal dyspnea, constipation, diarrhea, sore throat,\n myalgias, nausea, vomiting\n Allergies:\n Vicodin - Hallucinations\n Morphine Sulfate - Confusion/Delir\n Gabapentin - Extremities shake\n TRANSFER MEDICATIONS:\n 1) HYDROmorphone (Dilaudid) 0.12 mg IV PCA\n 2) Phenylephrine 0.5-5 mcg/kg/min IV DRIP\n 3) Vancomycin 1000 mg IV Q 12H for 2 doses post-op\n 4) Fluticasone Propionate NASAL 1 SPRY NU \n 5) Enoxaparin Sodium 40 mg SC Q24H\n 6) Pramipexole *NF* 0.125 mg Oral QD\n 7) LaMOTrigine 225 mg PO DAILY\n 8) Tamsulosin 0.4 mg PO HS\n 9) Losartan Potassium 50 mg PO DAILY\n 10) Furosemide 80 mg PO BID:PRN edema\n 11) Ipratropium Bromide MDI 2 PUFF IH Q 8H\n 12) Lactulose 30 mL PO/NG DAILY\n 13) Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n 14) Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n 15) Insulin SC (per Insulin Flowsheet)\n 16) Ondansetron 4 mg IV Q8H:PRN nausea/vomiting\n 17) DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis\n 18) Zolpidem Tartrate 2.5-5 mg PO QHS:PRN Insomnia\n 19) Promethazine 12.5-25 mg IV Q6H:PRN nausea\n 20) Milk of Magnesia 30 ml PO BID:PRN Constipation\n 21) Senna 1 TAB PO BID:PRN Constipation\n 22) Bisacodyl 10 mg PO/PR DAILY:PRN Constipation\n 23) Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q6H:PRN\n Dyspepsia\n 24) Docusate Sodium 100 mg PO BID\n 25) Pantoprazole 40 mg PO Q24H\n 26) OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain\n 27) BiPAP I=16, E=13, supplemental oxygen=4L\n Past medical history:\n Social History:\n 1) Diabetes mellitus II c/b neuropathy, nephropathy, retinopathy\n 2) Chronic diastolic CHF\n 3) Chronic kidney disease (baseline Cr 2.4 - 2.8)\n 4) OSA (Mask Choice: Swift II NV, DME Ordered: BiPAP 16/13; EERS\n 100, 4L O2)\n 5) Polyneuropathy (hand and feet)\n 6) Spinal stenosis\n 7) Severe degenerative arthritis\n 8) Anemia of chronic disease\n 9) Chronic restrictive ventilatory disease due to bile leak resulting\n in pulmonary fibrothorax requiring decortication\n 10) PVD w/ lower extremity claudication\n 11) Benign prostatic hyperplasia\n 12) Glaucoma; on carbonic anhydrase inhibitor\n 13) Bilateral cataracts s/p surgical removal\n 14) Depression\n 15) Erectile dysfunction s/p penile implant \n Surgical History:\n 1) Roux-en-y reconstruction after laparoscopic cholecystectomy c/b\n damage to CBD\n 2) decortication for fibrothorax complicated by respiratory\n failure requiring tracheostomy\n 3) Appendectomy\n 4) Left knee/hip replacement\n 5) L shoulder AC resection\n Patient lives with his wife. Former manager at Polaroid and then was a\n sports referee for many years. He is essentially independent in his\n daily activities, though needs some help getting dressed with certain\n clothing items. Has not driven in 6 years.\n Tobacco: Denies any history\n EtOH: 2-3 beers per month\n Illicits: Denies any history\n Family History:\n Brother-, h/o several strokes.\n Mother-dead in 70s from breast cancer.\n Father-dead at 61 from complications of emphysema, CHF.\n All children in good health.\n Physical Examination\n VS: T 97.8, HR 87, BP 91/56, RR 12, O2Sat 100% 2L NC\n GENERAL: NAD aside from occasional right groin pain\n HEENT: PERRL, EOMI, no conjunctival pallor, no scleral icterus, oral\n mucosa and lips extremely dry\n NECK: Supple, No LAD, No thyromegaly, no JVP elevation\n CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G\n LUNGS: attenuated and decreased anterior breath sounds with basilar\n crackles noted at midaxillary line bilaterally and anterior, unable to\n obtain posterior exam due to patient positioning\n ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic\n EXTREMITIES: Trace bipedal edema, compression stockings and pneumoboots\n in place, right hip with large C/D/I bandage overlying, right thigh\n soft though tender in right groin area, bilateral radial pulses and\n hand cap refill preserved\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 01:22PM\n 18.4*#\n 3.40*\n 10.7*\n 30.4*\n 89\n 31.4\n 35.2*\n 13.7\n 220\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [2] 01:22PM\n 230*\n 92*\n 2.8*\n 138\n 3.9\n 100\n 28\n 14\n CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n [3] 01:22PM\n 8.2*\n 5.4*#[1]\n 2.2\n TTE (Complete) :\n Conclusions\n The left atrium is elongated. Left ventricular wall thickness, cavity\n size and regional/global systolic function are normal (LVEF >55%).\n There is no ventricular septal defect. Right ventricular chamber size\n and free wall motion are normal. The diameters of aorta at the sinus,\n ascending and arch levels are normal. The aortic valve leaflets (3) are\n mildly thickened but aortic stenosis is not present. No aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. There is at least mild pulmonary\n artery systolic hypertension (TR spectral signal poor quality). There\n is no pericardial effusion.\n CARDIAC PERFUSION PERSANTINE :\n IMPRESSION:\n New partially reversible mild perfusion defect in the inferolateral\n wall without associated wall motion abnormality. EF 74%.\n Assessment and Plan\n 67 yo M with complicated past medical history who had an elective total\n right hip arthroplasty earlier today.\n .\n #. Post Operative Hypotension:\n Patient with post-operative hypotension requiring phenylephrine to keep\n mean blood pressure in the 60s. Hypotension associated with urine\n output less than 5 mL/hr. Patient clinically appears to be dry and he\n is complaining of thirst and a feeling of sand in his mouth. Possible\n that his hypotension is from intravascular depletion despite 3.5 L\n fluid intraoperatively. The stress of the operative could have caused\n third-spacing of fluids and subsequent intravascular depletion.\n Additionally, patient could be dry from blood loss into his operative\n site. This can be monitored with serial HCT as well as with exam to\n assure no increase in pain, size, or firmness of right thigh. Patient\n has a history of diastolic heart failure requiring TID furosemide and\n close weight monitoring, so it is possible that his hypotension is\n related to cardiogenic shock from heart failure; however, his clinical\n exam does not support this as his JVP is not elevated, oral mucosa is\n dry, lungs are essentially clear, and no peripheral edema appreciable.\n Possible that patient experienced an intraoperative MI, so will check a\n post-op EKG. He has no complaints of chest pain.\n - Liberate from phenylephrine as tolerated\n - Serial HCT to assure no ongoing or acute blood loss\n - EKG to assess for changes from pre-op\n - Trial of small fluid boluses to assess for decreased phenylephrine\n requirement and increased urine output\n - Consider ECHO to assess for any changes in cardiac function from\n prior\n - Hold home furosemide, losartan pending improvement in blood pressure\n #. Post-op course:\n Patient overall well controlled with only occasional bouts of right\n groin pain.\n - Appreciate surgery input for all post-op managment decisions\n - Vancomycin Q12H for two doses for prophylaxis\n - Drain care and dressing changes per surgery\n - Dilaudid PCA overnight\n - Low dose lorazepam for spasms\n #. Diabetes mellitus:\n - Diabetic diet\n - QID fingersticks\n - Glargine 18 units QHS and humalog sliding scale\n #. OSA:\n - Continue nightly home BiPAP at IPAP=16 and EPAP=13 with 4L oxygen\n #. Chronic diastolic CHF:\n - Monitor volume status with rehydration. Use small boluses to avoid\n volume overload.\n - Daily weights\n - Hold furosemide until hypotension resolves\n #. Chronic kidney disease:\n - Monitor post-op creatinine.\n - Avoid nephrotoxic agents.\n - Renally dose medications.\n ICU Care\n Nutrition: Full liquid diabetic diet, advance as tolerated to regular\n diabetic diet\n Glycemic Control: Glargine and humalog\n Lines:\n Arterial Line - 08:00 PM\n 20 Gauge - 08:44 PM\n 18 Gauge - 08:46 PM\n Prophylaxis:\n -DVT ppx with enoxaparin 40 mg Q24H\n -Bowel regimen\n -Pain management with dilaudid PCA\n Communication: With patient and wife, \n who is HCP\n status: FULL\n Disposition: ICU while on vasopressors and hypotensive\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_4%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_6%22);\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394617, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received IVF intraop, lost\n 600cc blood. In PACU became hypotensive, given 1 U PRBCs. Hct measured\n at 30, down from 34. Given neosynephrine.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394715, "text": "HPI:\n 67M underwent R hip arhtroplasty today, received 3500cc IVF intraop,\n lost 600cc blood, UOP 965cc. In PACU became hypotensive with low UOP,\n given 1 U PRBCs. Hct measured at 30, down from 34. Given neosynephrine.\n Tx on neo gtt, PCA dilaudid for pain control.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p r hip arthroplasty. R hip drsg d&I without drainage. Hemovac\n drained 50cc\ns blood. Received on dilaudid pca without basal rate. Pt\n yelling out and moaning in pain that increased in intensity with any\n nursing care that was never totally relieved with pca pain control.\n Positive csm to right foot.\n Action:\n Suregery by to evalauate pt. dilaudid pca d/c\nd and changed to po\n dilaudid. Medicated x2 with 2.5 mg ivp valium for ? anxiety component\n that might have intensified the level of his pain. Hemovac drsg d/c\n by surgery. Pt consulted for increase in activity. Pt repositioned\n from side to side. Once pca pump was d/c\nd pt was medicated with 2 mg\n po dilaudid.\n Response:\n R hip drsg &i. wife in to visit and pt no longer yelling out\n or moaning in pain. Appears more comfortable than this am,\n Plan:\n Plan is for r hip drsg be changed by surgery in the am. Will\n continue to medicate with po dilaudid as needed for pain control.\n Increase pt\ns level of activity as per recs of physical therapy.\n Monitor csm to r lower extremity. Emotional support to pt and his wife.\n Hypotension (not Shock)\n Assessment:\n Received pt on neogtt at 0.5mcg/kg/min which needed to be increased for\n a short period of time to 0.7mcg/kg/min. to maintain map>60 or sbp>\n 90. lower than nbp cuff. Adequate hourly uo continues.\n Hypotension most likely due to being intravascularly depleted despite\n lots of ivf intraoperatively.\n Action:\n Pt transfused with 2^nd unit of prbc\ns. neo gtt weaned to off. Given\n 500cc bolus of rl. Repeat hct sent off. Hemodynamics and uo followed\n closely.\n Response:\n Now with adequate hourly uo. Sbp now > 90 off pressors.\n Plan:\n If uo drops off or sbp drops below 90 will consider additional boluses\n of ivf. Follow hcts as ordered and transfuse prbc\ns as needed.\n" }, { "category": "Radiology", "chartdate": "2145-11-02 00:00:00.000", "description": "HIP 1 VIEW", "row_id": 1110115, "text": " 11:37 AM\n HIP 1 VIEW Clip # \n Reason: TOTAL HIP REPLACEMENT\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT HIP\n\n CLINICAL HISTORY: Total hip replacement.\n\n Two AP films are submitted.\n\n Since the study of , the patient has undergone a total hip\n arthroplasty. The current films are somewhat limited by exposure. The\n metallic components are in expected position. There is a cerclage wire at the\n level of the lesser trochanter. The penile prosthesis is partially\n visualized.\n\n IMPRESSION: There has been a total hip arthroplasty.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-11-02 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 1110150, "text": " 1:49 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: sponges, implant\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with R THA\n REASON FOR THIS EXAMINATION:\n sponges, implant\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE RADIOGRAPH OF THE PELVIS\n\n INDICATION: Right THA.\n\n COMPARISON: Intraoperative radiographs earlier and\n radiograph of pelvis and right hip .\n\n FINDINGS: Radiograph of pelvis performed provided is for\n interpretation on . This demonstrates bilateral total hip\n arthroplasty. A left hip arthroplasty is unchanged in position compared to\n examination in . There is no evidence of hardware loosening or\n hardware complication.\n\n The right hip arthroplasty is in near anatomic alignment. The inferior end of\n the femoral component is not completely included in the radiograph. No acute\n fracture or focal bone lesion is seen. Note is made of vascular\n calcification.\n\n IMPRESSION: Bilateral hip arthroplasties with no evidence of hardware\n complication of the visualized portions of the hardware.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2145-11-04 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1110459, "text": " 9:35 AM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: implant\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with R THR\n REASON FOR THIS EXAMINATION:\n implant\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right THR.\n\n FINDINGS: In comparison with the study of , there is little overall\n change in the appearance of the total hip prosthesis. No evidence of\n hardware-related complication. Similar prosthesis is seen on the left.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2201-06-22 00:00:00.000", "description": "Report", "row_id": 84218, "text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary embolus.\nHeight: (in) 64\nWeight (lb): 140\nBSA (m2): 1.68 m2\nBP (mm Hg): 105/65\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 22:12\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: No MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe\n[3+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality as the patient\nwas difficult to position.\n\nConclusions:\nThere is moderate symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). The right ventricular\ncavity is mildly dilated with moderate global free wall hypokinesis and apical\nsparing (+ Mconnells sign for acute pulmonary embolism). No aortic\nregurgitation is seen. No mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is a\nvery small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nIMPRESSION: RV strain, significant TR and moderate pulmonary hypertension.\n\n\n" }, { "category": "Echo", "chartdate": "2201-06-23 00:00:00.000", "description": "Report", "row_id": 84179, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 98/64\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 13:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Low normal LVEF. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV cavity. RV function\ndepressed. Abnormal septal motion/position consistent with RV pressure/volume\noverload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta. Normal aortic arch diameter. Focal calcifications in aortic arch.\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. of the\nmitral chordae (normal variant). No resting LVOT gradient. Calcified tips of\npapillary muscles. No MS. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate to severe [3+] TR. Given severity\nof TR, PASP may be underestimated due to elevated RA pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nunusually small. Overall left ventricular systolic function is low normal\n(LVEF 50%). The right ventricular free wall thickness is normal. The right\nventricular cavity is dilated with depressed free wall contractility. There is\nabnormal septal motion/position consistent with right ventricular\npressure/volume overload. The ascending aorta is mildly dilated. There are\nfocal calcifications in the aortic arch. 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. Moderate to severe (3+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. Moderate to severe [3+]\ntricuspid regurgitation is seen. [In the setting of at least moderate to\nsevere tricuspid regurgitation, the estimated pulmonary artery systolic\npressure may be underestimated due to a very high right atrial pressure.]\nThere is a small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the appearance of mitral regurgitation is increased, but may be so due\nto technical factors. The left ventricular ejection fraction is reduced, most\nlikely as a result of ventricular interaction with a pressure and volume\noverloaded right ventricle.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244476, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for acute cardiopulmonary process\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with post-op pulmonary embolism and right heart failure with\n new fever\n REASON FOR THIS EXAMINATION:\n evaluate for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Postop PE, right failure and fever.\n\n Comparison is made with prior study, .\n\n There are lower lung volumes. Large right and small-to-moderate left pleural\n effusions have decreased. They are associated with adjacent atelectasis.\n Cardiomegaly is accentuated by the low lung volumes. There is mild vascular\n congestion. There is no evident pneumothorax. Lumbar spine hardware is\n partially imaged.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243827, "text": " 12:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia vs atelectasis\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with postop fever\n REASON FOR THIS EXAMINATION:\n r/o pneumonia vs atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Postop fever.\n\n Comparison is made with prior study, .\n\n There are low lung volumes. There is mild cardiomegaly, accentuated by the\n low lung volumes. Left lower lobe opacity has markedly improved consistent\n with resolving atelectasis. Remaining opacities in the lower lobes\n bilaterally, larger on the right side, are likely atelectasis. Superimposed\n infection cannot be totally excluded in the appropriate clinical setting. If\n any, there are small bilateral pleural effusions. There is mild vascular\n congestion. There is no evident pneumothorax. Spinal hardware is\n incompletely imaged.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244210, "text": " 2:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulmonary edema, PNA\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with likely PE, hypotension\n REASON FOR THIS EXAMINATION:\n eval pulmonary edema, PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible PE with hypotension.\n\n FINDINGS: In comparison with the study of , there is increased\n opacification in the right hemithorax obscuring the hemidiaphragm. This is\n consistent with layering pleural effusion. Continued opacification at the\n left base with poor definition of the hemidiaphragm, consistent with volume\n loss in the left lower lobe and possible small effusion on this side.\n\n Enlargement of the cardiac silhouette with mild elevation of pulmonary venous\n pressure persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244034, "text": " 7:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for acute process\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p spinal fusion, now with SOB and hypotension\n REASON FOR THIS EXAMINATION:\n please evaluate for acute process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with shortness of breath\n and history of spinal fusion.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Heart size and mediastinum are unchanged in appearance including cardiomegaly.\n Bibasal atelectasis and bilateral pleural effusion is unchanged. No\n appreciable pneumothorax is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-06-17 00:00:00.000", "description": "LUMBAR SINGLE VIEW IN OR", "row_id": 1243434, "text": " 12:48 PM\n LUMBAR SINGLE VIEW IN OR; LUMBAR SINGLE VIEW IN OR Clip # \n -59 DISTINCT PROCEDURAL SERVICE; LUMBAR SINGLE VIEW IN OR\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: POST. T11-S1 REVISION/FUSION\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Five intraoperative radiographs of the thoracolumbar spine .\n\n COMPARISON: Radiographs .\n\n INDICATION: Status post T11-S1 revision fusion.\n\n FINDINGS AND IMPRESSION: Endotracheal tube and temperature probe present.\n Status post thoracolumbar T11-S1 revision fusion. Please see operative report\n for further details.\n\n" }, { "category": "Radiology", "chartdate": "2201-06-23 00:00:00.000", "description": "LUNG SCAN", "row_id": 1244062, "text": "LUNG SCAN Clip # \n Reason: 70 Y/O WOMAN W/ EKG AND ECHO FINDINGS CONCERNING FOR PE. EVAL FOR PE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 7.7 mCi Tc-m MAA ();\n 44.0 mCi Tc-99m DTPA Aerosol ();\n HISTORY: EKG and ECHO findings concerning for pulmonary embolism.\n\n\n INTERPRETATION:\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate\n subsegmental defects in the right lower lobe and left lower lobe.\n\n Perfusion images in the same 8 views show several subsegmental defects in the\n right lower lobe and left lower lobe which match, along with several\n subsegmental defects in the right and left upper lobes which do not match.\n\n Chest x-ray shows small left pleural effusion and left infrahilar consolidation\n\n\n The above findings are consistent with a moderate likelihood of pulmonary\n embolism.\n\n IMPRESSION:\n Moderate likelihood of pulmonary embolism.\n\n These findings were discussed by Dr. with Dr. via telephone at\n 5:50 am on .\n\n\n\n , M.D.\n , M.D. Approved: 3:54 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": "2201-06-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1243917, "text": " 10:19 PM\n CHEST (PA & LAT) Clip # \n Reason: Pneumonia vs. pulmonary congestion.\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with fever to 102 and tachycardia.\n REASON FOR THIS EXAMINATION:\n Pneumonia vs. pulmonary congestion.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: 70-year-old woman with fever of 102 and tachycardia. Suspect\n pneumonia or pulmonary congestion.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small left pleural effusion and new left infrahilar consolidation are most\n readily explained by atelectasis, but there is no way to exclude pneumonia.\n The upper lungs are clear. The heart is top normal size. No pneumothorax.\n\n Spinal stabilization device in place is not evaluated by this study.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-06-20 00:00:00.000", "description": "SCOLIOSIS SERIES", "row_id": 1243807, "text": " 3:50 PM\n SCOLIOSIS SERIES Clip # \n Reason: r/o hardware displacement\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with osteotomy L3\n REASON FOR THIS EXAMINATION:\n r/o hardware displacement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Scoliosis series, .\n\n CLINICAL HISTORY: 70-year-old woman with osteotomy at L3. Evaluate for\n hardware displacement.\n\n FINDINGS: Comparison is made to prior study from .\n\n Patient is status post posterior lumbar fusion spanning T9-S1 on the right and\n T10-S1 on the left. There is a right-sided spinal rod construct to the right\n of the fusion at the level of L2-L4. Patient is status post placement of\n lucent disc prostheses at several levels. There is anterolisthesis of L4 over\n L5 which is grade 1. There is a severe compression deformity at T9. These\n findings are relatively stable when compared to the intraoperative study from\n . There are fixation screws in the right proximal femur.\n\n" }, { "category": "Radiology", "chartdate": "2201-06-22 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1244044, "text": " 9:54 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please evaluate for DVT\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p spinal fusion, now with hypotension, tachycardia,\n equivocal evidence of right heart strain on exam.\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with bilateral lower extremity swelling.\n\n COMPARISON: None available.\n\n FINDINGS: Grayscale and Doppler son of bilateral common femoral,\n superficial femoral, and popliteal veins were performed. There is normal\n compressibility, flow, and augmentation. Edema is noted in bilateral\n popliteal regions. In the left popliteal fossa, there is a 3.1 x 1.7 x 2.6 cm\n cyst. In the right popliteal fossa, there are two cysts with\n the first measuring 4.5 x 2.3 x 4.6 cm with a septation and the second\n measuring 2.9 x 3.2 x 1.5 cm. The left posterior tibial and peroneal veins\n demonstrate normal flow. The right calf veins are limited in evaluation.\n\n IMPRESSION:\n 1. No evidence of right or left lower extremity DVT. The right calf veins\n are limited in evaluation.\n 2. Bilateral cysts with one in left popliteal fossa and two in the\n right popliteal fossa as described above.\n\n\n" }, { "category": "ECG", "chartdate": "2201-06-23 00:00:00.000", "description": "Report", "row_id": 224976, "text": "Sinus rhythm. Low voltage throughout. RSR' pattern in early precordial leads.\nConsider inferior myocardial infarction in evolution. Precordial T wave\ninversions, consider extension of the infarct pattern. Clinical correlation is\nsuggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2201-06-22 00:00:00.000", "description": "Report", "row_id": 224977, "text": "Sinus rhythm. RSR' pattern in leads V1 and V2. Small Q waves versus R waves\nin the inferior leads with inferior T wave inversions - possible inferior\nmyocardial infarction in evolution. Precordial leads now have minimal T wave\ninversions, directionally and similar magnitude relative to earlier .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2201-06-22 00:00:00.000", "description": "Report", "row_id": 224978, "text": "Baseline artifact. Sinus rhythm. ST segment elevation and T wave inversions\nin the inferior leads. Consider inferior myocardial infarction. Precordial\nleads are difficult to interpret. However, there is consistent low voltage and\npossibly anterolateral ST segment elevation and T wave inversion. Since the\nprevious tracing of the inferior ST-T wave abnormalities are new, the\nQRS complexes are probably fairly similar but the ST-T wave abnormalities may\nbe artifactual. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2201-06-17 00:00:00.000", "description": "Report", "row_id": 224979, "text": "Sinus rhythm. Possible left atrial abnormality. Overall, unremarkable\ntracing. Compared to the previous tracing of , no diagnostic change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2104-12-09 00:00:00.000", "description": "Report", "row_id": 1338202, "text": "SICU nursing progress note 7p-7a\nPlease refer to careview flowsheet for specific info.\n\nNeuro: Awake and alert, Oriented x 3. Following commands and making requests r/t pain control, and comfort measures, etc...\n\nPain: On Fentanyl drip at 100 mcg/hour, Fentanyl patch 300 mcg/hour, Oxycodone q 12 hours, and dilaudid po for breakthrough pain. Appears uncomfortable at times and rates pain a / of 10. Improves with dilaudid for breakthrough pain rating pain 6, and resting quietly with eyes closed.\n\nResp: Breath sounds clear and equal bilaterally, O2 nasal cannula at 2L/min. Resp rate regular. Shallow breaths when speaking. Incentive spirometry to 750 mL. Cough and deep breathing encouraged and patient compliant with above. O2 saturation >99%.\n\nCV: SR no ectopy. Well perfused with brisk capillary refill < 2seconds\n\nGI/ Abd: ON clear liquid diet, po encouraged. Active bs x 4, No stool, passing gas. Staples intact, small to mod. amount serosanguinous on dressing. JP x 2 with serosanguinous drainage. T-tube with bilious colored drainage.\n\nGU: Foley to gravity draining clear yellow urine. 25-50cc/ hour. Dr. updated and encourages PO of clear liquids. Patient is compliant with encouragement.\n\nSocial: Daughter and friend in at bedside, updated and verbalize understanding.\n\nPlan: Cont to check bs q 6 hours, has required no insulin coverage thus far tonight. Cont to encourage po clear liquids. Encourage cough, deep breathing, and incentive spirometry q 2 hours and prn. Position change q 1-2 hours and prn as tolerated. Pain management as ordered with dilaudid po for breakthrough pain.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-10 00:00:00.000", "description": "Report", "row_id": 1338203, "text": ",rrt\npt. remained on current settings, no changes made.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-10 00:00:00.000", "description": "Report", "row_id": 1338204, "text": "data: pt readmit @2200->on pt had 2 seizures->head ct neg. pt initially very somulent-not following commands, pupils 2 sluggish rx to light. neurology in to evalulate pt. @0300 pt more awake-following commands. alert and oriented. pupils 3 brisk rx to light. no seizure\nactivity seen.\nplt ct low 22-2pks of plts transfused repeat plt ct 50.\nlumbar puncture on hold b/c low plt ct.\nmri to be done today.\nabd. soft-+bs. jp lateral#2 mod. amt bloody drainage. dsg changed for mod sero-sang from around jp's sites.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-11 00:00:00.000", "description": "Report", "row_id": 1338207, "text": "focus update note\nafebrile, vss, hct 24 transfused with 1 unit prbc, no post transfusuion hct at this time, transfusion just completed, kcl repleated with 40 kcl, mag repleated with 2 grams mag so4, plat 64(heparin on hold), to transfuse with plat below 50, continue to monitor q 6 hour hct. plat, potassium.\n\nresp: o2sat at 2 -4liters via n/c, pt needs encouragement to cough and deep breath, lsc.\n\nneuro:alert to lethargic at times, sleeping on/off, opens eyes spontaneously, consistently calm cooperative, following commands, mae+, pupils 2-3 mm and brisk reaction to light and accomodation, at times pt only alert to name, pt appears confused frequently especially this am seeing and talking about people and places that are not present, frequent non sensical talk, pt went for MRI of head today which was consistent with hypodense areas indicative of ?prograft toxicity- awaiting trough from today, prograft on hold- this information per nursing discussion with transplant team, also pt +cmv but this does not indicate active cmv infetion per transplant resident.no seizure activity noted\n\nmobility: pt oob to chair with assist of 2m tolerated well\n\ndiet: pt advanced to regular diet at breakfast tolerated clear liqs, dinner tolerated , apple crisp, milk.\n\nGU/GI: bs positive + flatus no bm, lasix 20 mg , excellent diuresis,urine light yellow clear.\n\nendocrine: fs at 1000 115, at 1800 178 2 units regular insulin given\n\npain: fentanyl patches changed today 300 mcqs applied, no other pain medicine required, pt very comfortable today.\n\nsoical: daughter today\n\nplan: continue with serial platlets, hct, potassium, continue with diuresis, continue to moniotr neuro status closely and monitor for seizures, ? pt may go to floor when plat hct more stable.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-12 00:00:00.000", "description": "Report", "row_id": 1338208, "text": "NURSING NOTE\n VSS, AFEBRILE. STABLE OVERNIGHT, HCT AND PLT LEVELS STABLE.PAIN SEEMS TO BE WELL CONTROLLED WITH CURRENT REGIMEN. TRANSFER TO FLOOR TODAY. PLEASE SEE CARE VUE FOR FULL DETAILS AND SPECIFICS.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-06 00:00:00.000", "description": "Report", "row_id": 1338197, "text": "CONDITION UPDATE:\nD/A: T MAX 99.6\n\nNEURO: POST EXTUBATION, PT A+OX2, MAE, FOLLOWS COMMANDS. PT COMPLAINING OF SEVERE PAIN POST EXTUBATION. MORPHINE GIVEN WITH NO EFFECT. DR. ORDERED HYDROMORPHONE Q 5 MINUTES TO MAXIMUM DOSE OF 5MG. GIVEN OVER THE COURSE OF 45 MINUTES WITH POOR EFFECT.\n\nCV: HR 80'S NSR. ABP ~ 140/70. PA CATHETER REMOVED, CHANGED TO A TLCL. LINE NEEDED TO BE PULLED BACK X2 TIMES. OK TO USE PER DR. . CVP ~6. ONE UNIT PRBC GIVE FOR HCT OF 25.8. REPEAT HCT PENDING. 2 UNITS OF PLATELETS GIVEN FOR PLT 57, REPEAT COUNT 119. FLUID BALANCE MN-1800 +2700 CC'S. + PPP BILAT. NO SC HEPARIN AS OF YET PER TRANSPLANT TEAM. P BOOTS ON.\n\nRESP: PT EXTUBATED, BREATHING EASILY ON 40% HUMIDIFIED FACE TENT. POST EXTUBATION ABG: 7.41, 37, 98, 0, 24.\n\nGI: NPO. NGT WITH OLD BLOODY DRAINAGE. JP X2 WITH MINIMAL AMOUNTS OF SANGUANOUS DRAINAGE. T TUBE WITH ~ 80CC'S Q 4 HOURS OF BILE. DRESSINGS AROUND DRAINS CHANGED WITH MODERATE AMOUNT OF SANGUANOUS DRAINAGE. NO BS. NO NAUSEA. INSULIN GTT.\n\nGU: FOLEY-BSD WITH CLEAR ICTERIC URINE. 20-100 CC'S/HR.\n\nSKIN: INTACT, NO BREAKDOWN. INCISION AS ABOVE.\n\nSX: PT'S DAUGHTER CALLED X2.\n\nR: EXTUBATED, PA LINE D/C'D WITH PAIN CONTROL ISSUES.\n\nP: CONTINUE TO MONITOR HEMODYNAMICS, RESP STATUS, CARDIAC STATUS. LABS AS ORDERED. MONITOR FOR S+S OF BLEEDING. IMMUNOSUPPRESIVES AS ORDERED. INSULIN GTT AS ORDERED. CONTINUE TO RE-EVALUATE AND OBTAIN BETTER PAIN CONTROL. PT AND FAMILY SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-12-08 00:00:00.000", "description": "Report", "row_id": 1338200, "text": "focus hemodynmics\ndata: neuro: alert and oriented but occasionally will become slightly confused. moves all extremities on the bed. perla and reacts briskly. engages in conversation.\n\nresp: o2sats 92-100%. breath soungs clear. coughing but not raising anything. o2 via nasal prongs at 2 liters.\n\ncardiac: remains in nsr. hct 30. plts 69. magnesium level 1.0.\n\ngu: foley patent and draining amber colored urine.\n\ngI abd soft and distended. incision approximated. mod amt of sero sang drainage oozing around jp's site. dsg changed x2. jp's patent and draining sero sang drainage. drains stripped q1hr. t tube patent and draining bile. taking po meds ok.\n\naction: labs as ordered. turned q1-2hrs in the bed. fentanyl gtt at 250mcg and tol well. abd dsg changed x2. jp's emptied q4hrs.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-08 00:00:00.000", "description": "Report", "row_id": 1338201, "text": "condition update\nsee carevue for details\nneuro: alert/oriented x's 3. Slept on/off most of day, easily arousable. moves all extremities, normal strength. Pain moderately controlled with fentanyl gtt/transdermal patch, oxycontin, and dilaudid for breakthrough pain, pt not in apparent distress.\nCV: afeb, bp/hr stable.\nResp: shallow breaths, pt reports she is afraid to take deep breaths d/t pain. Pt appears breathless when speaking, sicu and transplant team made aware and in to examin pt. I/S teaching done/encourage, chest p.t. done, coughing/deep breathing encouraged. LS clear. o2 sat 100% 3 n.c.\nGI: abd softly distend, +bs, +flatus. tolerated clear liquids, no bm. t-tube draining bilious, j.p.'s draining serosang. Lateral jp draining increased amts. (140cc) ~1200, transplant team notified, hct checked and stable. Transplant examined pt and jp.\nGU: foley putting out marginal amts. clear amber urine, transplant team aware. po fluid enouraged, ? lasix dose later if u/o not improved as per transplant team.\nEndo: no ssri coveraged needed\nPlan: pain control, wean fentanyl gtt off in am, po dilaudid for breakthrough pain. continue pulmonary toileting, encourage coughing/deep breathing/is. oob to chair tomorrow, ? transfer to floor if pain well controlled, continue clear liquids.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-10 00:00:00.000", "description": "Report", "row_id": 1338205, "text": "npn 0700-1900;\ncholangiogram done and eeg done results pending still waiting on head mri.\n\nneuro; lethargic at times opens eyes spontaneously and to voice.aoox2-3 mae to command able to help with turn. perla 2-3 mm occassionally says something bazarre but corrects self. no seizures today. started on kepra.\n\npain control; has fentanyl patch, oxycodone 20 mgs given dilaudid 4mgs x2 8am and 3pm.c/o of neck stiffness neuro felt poss due to seizures,\n\n resp; lungs clear upper diminshed at bases very difficult to pick up sats 96-99% rr 15-18.\n\ncvs; tmax 98. 102-122 bp 118-136/89.no ectopy noted.\n\ngu; diuresed with lasix 20 mgs i,v with good response.\n\ngi; npo belly distended pos bs pos flatus no stool c/o of\" needing to pee\" . no coverage on riss.\n\ndrains draining mod amounts of bile via t-tube draining sesanguinious drainage from jp's drainnnnnig 50-100 mls /hr via lateral jp/\n md transplant team aware.\n\nheme; plats down to 17- given 2x6 units plats up to 40 transfused with 6 more units in an attempt to get above 50 so pt can have lp.more plats on hold to be trans fused during lp .\n\nwounnd draining small amounts serosanguinous draining\n\nsoc; family into visit daughter updated by phone on pts. current condition\n\na/p; continue to monitor platlet count prepare for lp awaiting mri of head continue to follow hct.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-12-11 00:00:00.000", "description": "Report", "row_id": 1338206, "text": "NURSING\n VSS OVERNIGHT, AFEBRILE. CVP 8-13. DIURESED IN LARGE VOLUMES AFTER LASIX PUTTING OUT 2 LITERS IN 3 HOURS.POTASSIUM RECHECKED, <4 AFTER LASIX, REPLETED WITH 40 MEQ OF KCL IV PER TRANSPLANT TEAM.RECIEVED I UNIT OF PLATELETS AT 2200 TO BRING PLT LEVEL >50. LEVEL 67 AFTER UNIT, TEAM NOTIFIED SO THAT SPINAL TAP COULD BE PERFORMED. DUE TO WAITING PERIOD FOR ATTENDING TO ARRIVE FOR SPINAL, PLATELETS RECHECKED AT MIDNIGHT, LEVEL WAS 61. SPINAL DONE, FLUID SENT FOR CULTURE. ONE ADDITIONAL UNIT OF PLATELETS GIVEN DURING PROCEDURE. SITE CLEAN AND DRY, PATIENT KEPT IN SUPINE POSITION WITH HOB FLAT.\n CONTINUES TO COMPLAIN INTERMITTANTLY OF PAIN AT HER INCISION, DENIES NECK PAIN OR HEADACHE ALL NIGHT. MEDICATED WITH HYDROMORPHONE FOR BREAKTHROUGH PAIN WITH GOOD EFFECT.\n NO CALL FOR MRI, UNABLE TO FIT HER IN AS OF CURRENT TIME, WILL HAVE TO GO TODAY DURING THE DAY. NEURO STATUS REMAINS UNCHANGED, INTERMITTANTLY ORIENTED X2, OR X3, MOVING ALL EXTREMITIES, PUPILS EQUAL AND REACTIVE.\n CONTINUE TO MONITER AND FOLLOW LABS, HEMODYNAMICS, MRI TODAY. MONITER COMFORT LEVEL AND ADMINISTER PAIN MEDICATION AS NEEDED.\n\n" }, { "category": "Nursing/other", "chartdate": "2104-12-05 00:00:00.000", "description": "Report", "row_id": 1338194, "text": "Please See Carevue for Specifics.\nNeuro: Arousable when propofol lightened. Does not follow commands, does withdraw to nailbed pressure when propofol lightened. Morphine 2mg IV in the morning.\nCardio: HCT this morning decreased to 20, was transfused with 4units pRBC and HCT increase to 34. Last HCT was 29 and is to receive one unit pRBC. PA line does not wedge. CI , CO , CVP 6-8, SPAP 20-24, SBP 110-120's, NSR with rare episodes of PVC's. Afebrile. No edema, +PP. Received one unit platelets recheck was 129.\nRespir: O2 sat 100%, CMV: peep 5, rate 12, Vt 550, FiO2 .40. Lungs are clear to coarse and suctioned rarely for scant amounts of thin sang secretions.\nEndo: Insulin gtt started. Currently at 16units/hr and BS remain in the 200's.\nGI: Abd is softly distended with hypoactive BSX4. Lateral and Medial JP with sang drainage, T-tube with clear bilious drainage. NGT to LWCS with small amounts of blood drainage. No stool this shift.\nGU: foley, c/y/u. Urine low at 1800, transplant team aware, no intervention at that time.\nSKIN: DSD covering abd incision with staining noted.\nPOC: HCT >30, Platelets >75, urine output >25. Continue frequent Labs. Monitor JP drainage. Family aware of POC. Vent wean, ?extubation . Monitor skin integrity. Transfer to 10 Sunday .\n" }, { "category": "Nursing/other", "chartdate": "2104-12-06 00:00:00.000", "description": "Report", "row_id": 1338195, "text": ",rrt\npt. remained on current settings t/o shift, rsbi planned for a.m.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-07 00:00:00.000", "description": "Report", "row_id": 1338198, "text": "focus hemodynmics\ndata: neuro: alert and oriented with occ confusion.. to place and time. moves all extremities on the bed. becoming agitated with her pain issue. pt demanding more pain medication. dr in to see pt reqarding pain med. dr called regarding pain issue. at times banging arms on the rails with frustration and agitation. dr ordered ativan .5mg iv x1 per dr . only slept in very short naps.\n\nresp: remains extubated. breath sounds crackles in lower bases. chest pt done. 40% open face mask on. abg's ok.\n\ncardiac: remains in nsr. plts count 65 and 2 bags of plts given. hct 27 and 1unit prbc given.repeat 30.3.\n\ngu: foley patent and draining yellow urine. u.o has increased with > 50cc/hr.\n\ngI abd soft to touch. incision intact. jp's draining minimal amts of bloody drainage. lg amt of serosang drainage oozing from around the jp's. t tube patent and draining bile.\n\naction: labs done md. pump initiated and being tol ok. lg amt of serosang drainage oozing from jp's. t tube patent. insulin gtt and q1hr blood sugars done. on vanco, flagyl, levofloxcin iv.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-07 00:00:00.000", "description": "Report", "row_id": 1338199, "text": "CONDITION UPDATE:\nD/A: T MAX 98.6\n\nNEURO: PT ALERT AND ORIENTED X2. MAE'S, STRONG STRENGTHS, PERL, FOLLOWS COMMANDS. PT IN SEVERE PAIN THIS AM. DILAUDID INCREASED WITH NO EFFECT THEN D/C'D. FENTANYL IVP, THEN GTT STARTED. FENTANYL PATCHES APPLIED. OXYCONTIN GIVEN X1. FENTANYL BOLUS'S WHILE ON GTT GIVEN AND ATIVAN TOTAL 1MG GIVEN. PT FINALLY COMFORTABLE @ 1700. DR. , DR. , SICU/TRANSPLANT TEAMS AND PHARMACY ALL INVOLVED THE FREQUENTLY CHANGING AND LARGE DOSES OF PAIN MEDS IN EFFORTS TO MANAGE PT'S PAIN.\n\nRESP: LS CLEAR. NO SOB. NO COUGH. O2 SATS ~ 99-100% ON 2 L/M O2 VIA NC. WHEN PT FINALLY RESTING @ 1700, RR ~19, O2 SATS REMAIN ~ 100%.\n\nCV: HR 70'S-80'S NSR WITH NO ECTOPY. ABP PRESSURE ~ 25 POINTS HIGHER THAN NBP. 2 UNITS OF PLATELETS GIVEN IN PREPARATION TO D/C ALINE. ALINE D/C'D. PRESSURE HELD X 25 MINUTES WITH LEG KEPT IMMOBLIE. NO S+S OF HEMATOMA NOTED. CVP ~12. FLUID BALANCE MN-1700 -868 CC'S.\n\nGI: NPO. NGT D/C'D. PT ABLE TO TAKE PO MEDS. JP X2 WITH SANGUANOUS DRAINAGE. JP'S FREQUENTLY STRIPPED. DRESSING CHANGED X2. TRANSPLANT TEAM AWARE. T-TUBE WITH BILIOUS DRAINAGE.\n\nGU: FOLEY-BSD WITH CLEAR AMBER-YELLOW URINE.\n\nSX: PT'S DAUGHTER AND SISTER .\n\nR: PAIN UNDER BETTER CONTROL, VITALS STABLE, U/O BORDERLINE.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGMENET. PT AND FAMILY SUPPORT. CONTINUE TO RE-EVALUATE PAIN MANAGEMENT PLAN, ADJUST ACCORDINGLY. CONTINUE TO CLOSELY MONITOR RESP STATUS AND VITAL SIGNS.\n" }, { "category": "Nursing/other", "chartdate": "2104-12-06 00:00:00.000", "description": "Report", "row_id": 1338196, "text": "focus hemodymics\ndata: neuro: on propofol and off for neuro assessment. moves all extremities on the bed. attempts to grab at et tube. does not open eyes to command. withdraws to painful stimuli. hands restrainted for safety. perla # bilaterally.\n\nresp: remains intubated. suctioned for thick old bloody-tan-yellow sputum. o2sats 96-100%.resp . wgt up to 75.1 kg and dry wgt 65.9.\n\ncardiac: remains in nsr. k repleted and magneiusum repleted. wbc 27.3 and 1 unit prbc given with post hct 31.1. inr 1.3. pad 10-15. cco swan intact. svr 1100-1900. dr aware. plts 72-85 and 2 packs of plts given.\n\ngu: foley patent and draining a very small amt of urine. 0-40cc/hr. 2 liters ns iv bolus given. l\n\ngI abd soft distended. incision intact with staples present. jp's being stripped q1hr with emptying q2hrs. dsg changed x1. t tube patent and draining bilious bile. lft's coming down . ngt draining dark brown/ old bloody drainage.\n\naction: suctioned prn. labs as ordered. 1unit prbc given x1 2 units of plts given. mso4 2mg iv given for pain. propofol gtt infusing and off intermittently to assess movement. iv d51/2ns at 125cc/hr. t tube to self drainage. on iv vanco, levofloxacin, flagyl.fluconazole. ngt to lscws.\n\nresponse: monitor closely.\n" }, { "category": "Radiology", "chartdate": "2104-12-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 887548, "text": " 9:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? etiology of seizure: ?bleed, mass, ? hydrocephalus\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p liver transplant for HBV HCV now had onset of a\n clonic/tonic seizure. Pt stable now\n REASON FOR THIS EXAMINATION:\n ? etiology of seizure: ?bleed, mass, ? hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post liver transplant with chronic/tonic seizure.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: Study is slightly limited by patient motion.\n Allowing for this, there is no intra- or extra-axial hemorrhage, mass effect,\n or shift of midline structures. The differentiation of the and white\n matter is preserved. The ventricles, basal cisterns, sulci are unremarkable.\n There is no hydrocephalus. Mucosal thickening is seen involving the right\n maxillary sinus. The remaining visualized paranasal sinuses and mastoid air\n cells are clear. Surrounding osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION: No intracranial hemorrhage or mass effect. MRI is recommended\n for further evaluation.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2104-12-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 886869, "text": " 6:51 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check lines\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p RIJ Line\n REASON FOR THIS EXAMINATION:\n check lines\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant and central line placement.\n\n PORTABLE AP CHEST: Compared to preoperative radiograph of one-day prior, new\n endotracheal tube terminates approximately 2 cm above the level of the carina.\n Swan-Ganz catheter terminates within the right main pulmonary artery.\n Nasogastric tube courses well below the hemidiaphragms and beyond the confines\n of the image. Right internal jugular introducer sheath terminates within the\n mid SVC. Mild interstitial prominence is consistent with edema. There are no\n pleural effusions. Right upper quadrant drain is noted.\n\n IMPRESSION: Satisfactory positioning of lines and tubes. Mild interstitial\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2104-12-04 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 886847, "text": " 8:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: LIVER FAILURE\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with HCV cirrhosis here for potential liver transplant\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, pul. edema, and mass\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of hepatitis C cirrhosis, for liver transplant. Evaluate\n for infiltrate or pulmonary edema.\n\n COMPARISON: 9/20/5.\n\n PA AND LATERAL CHEST X-RAY: Lung fields are clear. The heart size and\n mediastinal contours are normal. No pleural effusions or pneumothorax are\n seen. The soft tissue and osseous structures are stable.\n\n IMPRESSION: No acute cardiopulmonary abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887070, "text": " 1:38 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p RIJ line\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p RIJ Line\n\n REASON FOR THIS EXAMINATION:\n s/p RIJ line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An IJ line.\n\n chest, 1 vw\n\n Compared with approximately one hour earlier, a repeat film has been obtained\n with less patient rotation (now actually rotated to the right).\n\n The right IJ central line tip overlies the right atrium and should be\n retracted approximately 5 cm. No pneumothorax is identified. Allowing for\n differences in positioning, pleural and parenchymal findings are otherwise\n unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2104-12-10 00:00:00.000", "description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER", "row_id": 887595, "text": " 9:18 AM\n CATH CHEK/REMV Clip # \n Reason: Please assess vasculature of hepatic vessels\n Admitting Diagnosis: LIVER FAILURE\n Contrast: OPTIRAY Amt: 25\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p liver transplantx 5 days assess patency of\n vasculature\n REASON FOR THIS EXAMINATION:\n Please assess vasculature of hepatic vessels\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is five days status post liver transplant. Assess\n patency of biliary tree.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. , with\n Dr. , the attending physician, and supervising. An initial\n fluoroscopic spot image demonstrates surgical staples overlying the skin in a\n chevron fashion, and an indwelling biliary catheter. A tube cholangiogram was\n subsequently performed. Roughly 20 cc of Optiray contrast was allowed to run\n into the indwelling biliary tube via gravity. The cholangiogram demonstrates\n a widely patent biliary anastomosis. Contrast flows freely into the duodenum\n without delay. The common bile duct, common hepatic duct, and inferior most\n right and left hepatic ducts opacify with contrast and appear normal. There\n is no evidence of leak. Intrahepatic biliary ducts were not opacified or\n visualized.\n\n IMPRESSION: Widely patent biliary anastomosis without leak. Intrahepatic\n biliary ducts not visualized.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-12-11 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 887784, "text": " 10:34 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: On FK506, with new seizure disorder; are there white matter\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with\n REASON FOR THIS EXAMINATION:\n On FK506, with new seizure disorder; are there white matter changes?\n ______________________________________________________________________________\n FINAL REPORT\n GADOLINIUM-ENHANCED BRAIN IMAGING\n\n HISTORY: Status post treatment with FK-506 with new seizure disorder. Are\n there any white matter changes ? S/P liver transplant.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted brain imaging was obtained, with\n gadolinium enhancement as well.\n\n FINDINGS: There are multiple small areas of elevated FLAIR signal, mostly\n cortical in locale, and somewhat clustered in the region of the posterior\n temporal and occipital lobes on both sides. A few additional hyperintense\n lesions are seen in a gyral distribution on the right at the vertex level. A\n 5 mm rounded zone of elevated FLAIR signal is seen within the posterior aspect\n of the right hippocampus, lateral to the incisura. There is no observable\n enhancement of these lesions. None of them are visible on diffusion-weighted\n images, either. There is no hydrocephalus or shift of normally midline\n structures. There is no evidence for abnormal susceptibility in the brain.\n There is a mild degree of T2 hyperintense material within the right mastoid\n sinus. This finding could represent inflammatory disease.\n\n The principal vascular flow patterns are identified.\n\n CONCLUSION: Multiple, largely cortically based areas of T2 hyperintensity\n with some clustering within the region of the occipital lobes. Given the\n history of immunosuppression, a reversible encephalopathic process should be\n considered. Upon discussion with Dr. , the attending neurologist, it\n appears that a lumbar puncture was obtained, which was unrevealing for\n infectious changes. Nevertheless, although one antiviral is currently\n being administered, consideration for addition of acyclovir was raised,\n although the pattern is by no means typical for the more commonly occurring\n form of herpes simplex encephalitis (frontal and temporal lobe involvement).\n\n MR ANGIOGRAPHY OF THE CIRCLE OF AND ITS TRIBUTARIES\n\n TECHNIQUE: Three-dimensional time-of-flight imaging with multiplanar\n reconstructions.\n\n FINDINGS: There is a 2 x 4 mm aneurysm arising posterolaterally from the\n supraclinoid portion of the left internal carotid artery. There are no other\n vascular abnormalities identified. These issues were also discussed with the\n (Over)\n\n 10:34 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: On FK506, with new seizure disorder; are there white matter\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n attending neurologist.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2104-12-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 887067, "text": " 1:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p d/c PA line changed to 3LC\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p RIJ Line\n\n REASON FOR THIS EXAMINATION:\n s/p d/c PA line changed to 3LC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right IJ line.\n\n CHEST, SINGLE AP SUPINE PORTABLE VIEW:\n Rotated positioning.\n\n An ET tube is present, in satisfactory position above the carina. An NG tube\n is present, tip beneath the diaphragm extending off the film. Right IJ\n central line is present. The tip is not optimally demonstrated, but the faint\n density appears to overlie the right atrium and should be retracted\n approximately 7.5 cm. There are low inspiratory volumes, likely accounting for\n much of the patchy opacity projecting over both lungs. Possibility of an\n underlying infectious infiltrate cannot be excluded. The right hemidiaphragm\n is slightly elevated. No pneumothorax is detected. Skin staples and a right\n upper quadrant drain overlie the abdomen.\n\n IMPRESSION: Right IJ central line tip overlies right atrium and should be\n retracted. No pneumothorax is detected. A wet was provided by Dr.\n .\n\n" }, { "category": "Radiology", "chartdate": "2104-12-05 00:00:00.000", "description": "P DUPLEX DOPP ABD/PEL PORT", "row_id": 886913, "text": " 10:13 AM\n DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: fresh liver transplant evaluate patency of vascular anastomo\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with HCV cirrhosis, p/w abd pain s/p OLT (liver\n transplant) today\n REASON FOR THIS EXAMINATION:\n fresh liver transplant evaluate patency of vascular anastomoses and for\n hematoma\n ______________________________________________________________________________\n FINAL REPORT\n LIVER ULTRASOUND:\n\n INDICATION: Status post transplant posttransplant evaluation for patency of\n arteries.\n\n Portable ultrasound was performed to evaluate liver following implantation.\n The study demonstrates normal appearing liver parenchyma with an approximately\n 7 x 10 cm hematoma in the right subhepatic space. This is causing some\n compression of the adjacent liver. No other perihepatic fluid collections are\n identified.\n\n Color flow and pulse wave Doppler images were performed, which demonstrates\n patent left, right, and middle hepatic veins with normal waveforms. The main,\n left, and right portal veins are patent and the main, left, and right hepatic\n arteries all patent. The waveforms are normal.\n\n IMPRESSION:\n 1. Patent hepatic vasculature following implantation with normal waveforms.\n\n 2. Approximately 7 x 10 cm hematoma in the right subphrenic space causing\n some compression of adjacent liver.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-12-16 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 888399, "text": " 11:28 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Rule out any cause for her previous seizures. Please do MRI\n Admitting Diagnosis: LIVER FAILURE\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p OLT, POD11, had seizures probably related to FK, on\n Keppra as per neuro. She had 3 post transplant seizures, likely from posterior\n leukoencephalopathy.\n REASON FOR THIS EXAMINATION:\n Rule out any cause for her previous seizures. Please do MRI with gadolinium.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizures post-orthotopic liver transplant, on immunosuppression.\n\n COMPARISON: MRI/MRA of the brain from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained.\n\n FINDINGS: The previously seen areas of elevated FLAIR signal in the posterior\n temporal and occipital lobes bilaterally have resolved. There are persistent\n hyperintense lesions in the white matter of the bilateral frontal lobes as\n well as in the right cerebellum. There is no intracranial mass lesion,\n hydrocephalus, shift of normally midline structures, or evidence of minor or\n major territorial infarctions. The surrounding osseous and soft tissue\n structures are unremarkable. There is again seen a mild degree of T2\n hyperintense material within the right mastoid sinus, possibly representing\n inflammatory disease.\n\n IMPRESSION: Resolution of the abnormalities in the occipital and posterior\n temporal lobes. This is consistent with a reversible encephalopathic process.\n\n" }, { "category": "ECG", "chartdate": "2104-12-09 00:00:00.000", "description": "Report", "row_id": 287531, "text": "Sinus tachycardia. Poor R wave progression. Anterolateral ST-T wave\nabnormalities. Since the previous tracing of rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2104-12-04 00:00:00.000", "description": "Report", "row_id": 287532, "text": "Sinus rhythm. Early R wave progression. Minor non-specific ST-T wave\nabnormalities. Since the previous tracing of no significant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2111-04-01 00:00:00.000", "description": "R CT UP EXT W/C RIGHT", "row_id": 1178314, "text": " 7:14 PM\n CT UP EXT W/C RIGHT Clip # \n Reason: please eval for evidence of necrotizing fascitis - severe ce\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with cellulitis\n REASON FOR THIS EXAMINATION:\n please eval for evidence of necrotizing fascitis - severe cellulits s/p\n shooting up 1 week ago, ? gas on x-ray, fever to 105\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 8:44 PM\n Numerous subq gas pockets tracking along the deep fascia, compatible with\n necrotizing fasciitis. Dr. discussed findings with the surgical team\n short after the completion of the exam.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER EXTREMITY CT PERFORMED ON .\n\n Comparison with an outside hospital radiograph from the same date.\n\n TECHNIQUE: Multidetector CT through the right arm was performed without\n contrast with multiplanar reformations.\n\n CLINICAL HISTORY: Right arm swelling, pain, bubbles of gas in the soft\n tissues on radiograph concerning for necrotizing fasciitis.\n\n FINDINGS: Diffuse edema within the soft tissues of the forearm and upper arm\n with a soft tissue defect noted along the radial aspect of the mid forearm.\n There is tracking soft tissue gas along the deep fascial intramuscular planes\n as well as edema which extends from the distal radius proximally to the level\n of the mid humerus. Findings are compatible with necrotizing fasciitis. A\n linear metallic foreign body measuring approximately 11 mm in length is\n embedded within the biceps muscle and is seen on series 7, image 95 and 96.\n It is likely that this foreign body is not related to the acute process. The\n imaged bones appear unremarkable with normal bony mineralization and no\n cortical destruction, or erosive changes to suggest osteomyelitis. Given that\n IV contrast was not administered, the evaluation for fluid collections is\n limited.\n\n IMPRESSION: Extensive subcutaneous and deep fascial edema with gas tracking\n along the deep fascial planes compatible with necrotizing fasciitis. The\n extent of involvement is detailed above, though extends from the level of the\n distal humerus through the level of the distal radius. Small retained foreign\n body embedded within the biceps muscle as detailed. No evidence of\n osteomyelitis.\n\n Findings were discussed with at the time of initial review.\n (Over)\n\n 7:14 PM\n CT UP EXT W/C RIGHT Clip # \n Reason: please eval for evidence of necrotizing fascitis - severe ce\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2111-04-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1178338, "text": " 12:25 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new L IJ CVL\n Admitting Diagnosis: NECROTIZING FASCITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with new cvl\n REASON FOR THIS EXAMINATION:\n new L IJ CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with new left internal\n jugular central venous line placement.\n\n AP radiograph was reviewed in comparison to CT of upper extremity obtained\n .\n\n Left internal jugular line tip is at the level of cavoatrial junction. There\n is no evidence of pneumothorax or apical hematoma after insertion.\n Cardiomediastinal silhouette is unremarkable. There is right lower lung\n opacity that potentially might represent developing/resolving infection and\n attention to this area should be paid on the subsequent radiograph.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2120-05-10 00:00:00.000", "description": "Report", "row_id": 1539223, "text": "CSRU NURSING NOTE:\n\n47YO MALE WITH HISTORY () OF STREP ENDOCARDITIS- HOSPITALIZED FOR 2 WEEKS IN . TX WITH 6WKS OF PCN. RESIDUAL 4+AR. CT SCAN IN SHOWED PULM NODULES- <5MM (? SEPTIC EMBOLI.) PRESENTED TO FOR CARDIAC CATH PRIOR TO AVR. REPEAT CT PRIOR TO OR SHOWED RESOLUTION OF PULM NODULES. CATH SHOWED CLEAN CORONARIES. PT HAS PSYCH HISTORY OF DEPRESSION AND FOLLOWED BY PSYCH.\n\nALLG: PCN\n\nPMHX: STREP ENDOCARDITIS\n AR\n DEPRESSION\n ++ETOH\n\n: PT UNDERWENT MINIMALLY INVASIVE AVR #21 PERICARDIAL VALVE. BPT: 1'\", XCT: 59\". ON EPI POST-BYPASS. NO OTHER GTTS.\n\nNEURO: PT ALERT, PROPOFOL BEING WEANED FOR EXTUBATION. PT ABLE TO MAE. FOLLOWING COMMANDS. SEEMS VERY CALM AT THE PRESENT TIME.\n\nCV: DENIES CP, PALP, SOB: TELE: ST INITIALLY, NOW NSR. ATRIAL WIRES INTACT AND SET FOR BACK-UP 60 BPM- PACE AND SENSE APPROPRIATELY. V WIRES NOT SENSING OR PACING. GENERALIZED EDEMA. PA LINE INTACT. GOOD CO/CI. EPI D/C'D - WILL MONITOR.\n\nRESP: LS CTA. CTX2 INTACT. MINIMAL OUTPUT- ON APROTININ INTRA-OP- FINISHING DOSE THEN WILL D/C. INTUBATED, ON CPAP, WILL AWAIT ABG FOR EXTUBATION.\n\nGI: ABD SOFT, NONTENDER. BS ABS. NO BM. OG TUBE DRAINING MINIMAL BROWN DRNG.\n\nGU: FOLEY INTACT. MAKING ADEQUATE URINE.\n\nID: COVERED WITH VANCO.\n\nPLAN: ? EXTUBATION. ADVANCE AS TOLERATED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-05-11 00:00:00.000", "description": "Report", "row_id": 1539224, "text": "UPDATE\nO: CV STATUS: SR NO ECTOPICS. CO/CI ADEQ ON SNP FOR MBP>100 SWITCHED BACK TO NTG FOR BP CONTROL IN VIEW OF MARGINAL PO2'S.DISTAL PULSES PALP FEET . CT'S TO SUCTION W MIN TO MOD CT DUMP W TURNING SIDE TO SIDE.PA PRESSURES LOW W CVP 6-1 AFTER RESTARTING NTG.HUO QS AMBER URINE HOLD ON ANY FLD FOR NOW PER DR .\n\nRESP STATUS: BILAT BRTH SNDS CLEAR BUT , PT SPLINTING W DB & C EXERCISES-> PERCOCET 2 TABS GIVEN W GD EFFECT.MOVING 500-750 CC W I/S.COUGHING W/O RAISING SPUTUM.SATS DWN TO 91% ? 2NDARY TO SHUNTING FROM SNP-> SWITCHED TO NTG W NO APPRECIABLE CHANGE. TURNED SIDE TO SIDE FOR DRAINAGE OF CT'S W SOME CLOTTY SS DRNG STILL NO APPRECIABLE CHANGE IN SATS. COOL MIST MASK APPLIED IN ADDITION TO NP ^ 5LPM SATS IMPROVED TO 95-97% ON OFM AT 70% AND NP AT 5 LPM.\n\nGI STATUS:PT STATES HE IS HUNGRY ? HYPOACTIVE BOWEL SNDS. TOL PO CRACKERS AND FLDS.\n\nGU STATUS: HUO QS AMBER URINE.\n\nLABS: STABLE LYTES AND HCT.\n\nNEURO/PSYCH: SOMEWHAT ANXIOUS AT TIMES W TURNING OR DB EXERCISES(PT W HX OF DEPRESSION &ETOH ABUSE ON MEDS FOR ANXIETY PREOP & FOLLOWING CIWA SCALE)PER HO -> PT TO RESTART VALIUM IN AM.CALMS & RESTING IN NAPS SUBSEQ TO PAIN MED PERC 2 TABS AT 0200.\n\nA/P: MINIMALLY INVASIVE AVR W HEMODYNAMICS STABLE POSTOP W EXCEPTION OF MARGINAL PO2'S. CONT TO MONITOR CIWA SCALE AND RESTART ANXIOLYTICS PER TEAM RECOMMENDATIONS.ADV W CARDIAC REHAB OOB TO CHAIR WHEN PA LINE PULLED BACK.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-05-11 00:00:00.000", "description": "Report", "row_id": 1539225, "text": "CSRU TRANSFER NOTE:\n\n47YO MALE WITH HISTORY OF PNEUMONIA AND SUBSEQUENT STREP ENDOCARDIDITS IN . PT HOSPITALIZED FOR 2WKS AND TX WITH 6WKS OF PCN. CT SCAN IN SHOWED MULTIPLE PULM NODULES <5MM (?SEPTIC EMBOLI). RESIDUAL 4+AR. PRESENTED TO FOR CARDIAC CATH PRIOR TO AVR. CLEAN CORONARIES. REPEAT CT SHOWED RESOLUTION OF PULM NODULES. PT HAS HISTORY OF DEPRESSION AND IS FOLLOWED BY PSYCH AS OUTPT.\n\nALLG: PCN\n\nPMHX: STREP ENDOCARDITIS\n AR\n DEPRESSION\n ++ ETOH\n\n: MINIMALLY INVASIVE #21 PERICARDIAL AVR. BPT: 1'\", XCT: 59\". ON EPI POST-BYPASS.\n\nNEURO: PT ALERT AND ORIENTED. CALM, SHAKY AS TIMES. STARTED BACK ON VALIUM 10MG PO BID TO PREVENT WITHDRAWALS. MOVING ALL EXTREMITIES AND FOLLOWING COMMANDS. FULLY APPROPRIATE.\n\nCV: PT DENIES CP, PALP, SOB. TELE: MP- NSR/ST: HR 90-100'S. BP STABLE. STARTED ON LOPRESSOR, NTG/SNP D/C'D. EPI D/C'D ON ARRIVAL TO CSRU- CO/CI STABLE. PA LINE D/C'D THIS AM. GENERALIZED 1+ EDEMA. CVP 10 THIS AM, LASIX ON HOLD. UOP MINIMAL.\n\nRESP: LS CTA. PT EXTUBATED AT 6:30PM - WELL. PT NEEDS ENCOURAGEMENT TO DB&C. USING IS WITH ENCOURAGEMENT. CTX2 D/C'D THIS AM WITHOUT DIFFICULTY.\n\nGI: ABD SOFT, NONTENDER. BS HYPO. NO BM. PT WITHOUT DIFFICULTY.\n\nGU: FOLEY INTACT. UOP FAIR. TEAM AWARE. HOLDING ON LASIX THIS AM.\n\nID: COVERED WITH VANCO.\n\nPLAN: INCREASE ACTIVITY AS TOLERATED. CONTINUE DT PRECUATIONS (MVI, THIAMINE, FOLATE, VALIUM.) MONITOR UOP.\n\n\n" }, { "category": "ECG", "chartdate": "2120-05-10 00:00:00.000", "description": "Report", "row_id": 153682, "text": "Sinus rhythm with tachycardia. Low amplitude T waves in lead I, newly inverted\nT waves in lead aVL. Prolonged P-R interval. Biphasic T waves in lead V3.\nINT: Abnormal ECG. Sinus tachycardia. Prolonged P-R interval. T wave\nabnormalities in leads V2-V3. Non-specific T wave abnormalities. Compared to\nthe previous tracing of all abnormalities have appeared.\n\n" }, { "category": "Radiology", "chartdate": "2120-05-08 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 756642, "text": " 2:07 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: History of 1cm lung nodules on chest CT. F/U eval.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with lung nodules and aortic regrurgitation\n REASON FOR THIS EXAMINATION:\n History of 1cm lung nodules on chest CT. F/U eval.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST .\n\n CLINICAL INDICATION: 47 year old man with history of lung nodules. Please\n reassess.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet through the upper abdomen without the administration of IV\n contrast.\n\n COMPARISONS: Comparison is made to the next prior CT study dated .\n\n CHEST CT WITHOUT IV CONTRAST: Soft tissue windows reveal a pretracheal lymph\n node which measures approximately 10 mm in short axis dimension. This node\n was not identified on the previous study. No other adenopathy is identified\n in the hilar or axillary regions. The heart and great vessels are\n unremarkable. There are no pericardial or pleural effusions.\n\n Lung windows again reveal several tiny noncalcified pulmonary nodules, all of\n which are unchanged in size and appearance since the previous study. No new\n pulmonary nodules are identified. The lungs are otherwise normal in\n appearance without focal areas of consolidation.\n\n Limited images through the upper abdomen reveal diffuse fatty infiltration of\n the liver. No focal hepatic lesions are identified. The adrenal glands,\n pancreas and spleen are all stable in appearance.\n\n Bone windows reveal minor degenerative changes of the lower thoracic spine. No\n destructive bone lesions are seen.\n\n IMPRESSION: No interval change in size or appearance of several tiny\n pulmonary nodules which may be post inflammatory in nature.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-05-09 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 756740, "text": " 7:39 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HX ENDOCARDITIS;AORTIC VALVE;PLANNED VALVE REPLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with AI. Preop for AVR in AM.\n REASON FOR THIS EXAMINATION:\n Preop for AVR in AM.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS PA & LATERAL:\n\n Preop AVR.\n\n Heart size is borderline. No evidence for CHF. The lungs are clear. No pleural\n effusions.\n\n IMPRESSION: No evidence for CHF or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2120-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756847, "text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: removal of chest tubes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with s/p cabg chest tubes removed today\n REASON FOR THIS EXAMINATION:\n removal of chest tubes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG\n\n COMPARISON: Preop film from 2 days earlier.\n\n PORTABLE CHEST: The patient is s/p median sternotomy s/p CABG. Cardiac\n silhouette does appear enlarged. This could reflect portable film technique\n in combination with low lung volumes. Cardiac silhouette is, however,\n somewhat globular raising the question of pericardial effusion.\n\n There are nonspecific areas of increased density in the right base medially\n and left retrocardiac area. This could reflect pleural effusion and/or\n atelectasis. The possibility of pneumonia cannot be entirely excluded. The\n remaining portions of the lungs do appear clear. No evidence of pneumothorax.\n\n IMPRESSION: 1. s/p interval median sternotomy s/p CABG.\n 2. See above comments regarding the appearance of the cardiac silhouette; as\n stated, pericardial effusion cannot be excluded.\n 3. New nonspecific areas of increased density in both bases as described.\n\n\n\n\n" } ]